OSCE stations

which women should be offered transdermal hormone therapy?

- Women at high risk for VTE - Women with malabsorption - Women with hypertriglyceridemia - Obese women with metabolic syndrome - Smokers - Women with hypertension - Women with sexual dysfunction

risks that increase breech

- uterine anomalies - pelvic tumors - placenta previa - hydrocephalus, anecephaly - oligohydramnios - uterine relaxation -> a) multiparity b) polyhydramnios c) multiple fetuses - previous breech

immediate fetal complications of breech

a. Birth trauma i. Fracture of clavicle, humerus, femur ii. SCM hematoma iii. Brachial plexus injury iv. Skull fractures v. Testicular injuries b. Increase in SIDS

SOGC stillbirth social support

brush up on this

perineal body muscles

bulbocavernosus the superficial transverse perineal muscles external anal sphincter

Yuzpe method How effective?

taking high-dose combined OCPs for emergency contraception, take 2 doses, 12 hours apart... number of tabs depends on the dose of the tabs. and can decrease the risk of pregnancy by about 60-80%.

relative contraindications to IUD

- Past history of progestin receptor positive breast cancer > 5 years ago - Severe decompensated cirrhosis, malignant hepatoma or hepatocellular adenoma - Complicated solid organ transplant - Postpartum ≥48hrs or <4 week

granulosa cell tumor presentation

- Precocious puberty (5% occur before puberty) - Menorrhagia - Post-menopausal bleeds - Cystic hyperplasia of the endometrium (25-50%) - Endometrial carcinoma (5-15%) - Pain, Ascites (10%) - Virilization - rupture with hematoperitoneum - secondary amenorrhea

pregnancy laparoscopy modifications

- Slight left lateral positioning of the patient during the second half of pregnancy, - Avoiding the use of any cervical instruments, - Consideration of open entry techniques or placement of trocars under direct visualization, - Limiting intra-abdominal pressure to less than 12 mmHg May need to move higher FHR before and after

Obesity cesarean incisions

- Vertical midline - Transverse infraumbilical - Transverse supraumbilical

semen volumes

- Volume >1.5mL; concentration >15 million/mL; total motility >40%; progressive motility >32%; normal morphology >4%

When to do IV iron pregnancy

- intolerance to oral iron - poor response to oral iron - malabsorption (ie, gastric bypass) - rapid correction needed - severe anemia (ie, <80)

symptoms of severe maternal varicella

- pneumonia - encephalitis - disseminated infection - immunocompromised

endometriosis physical exam findings

-Painful examination -Fixed, retroverted/retroflexed uterus -Presence of rectovaginal nodularity - Uterosacral tethering -Adnexal mass (endometrioma) -Bluish lesions of vagina (posterior fornix) on speculum

risks of assisted delivery

-advanced perineal laceration (3rd+4th degree tears) -cephalohematoma -intracranial hemorrhage - shoulder dystocia -brachial plexus injury

risks of hormone therapy

- Breast cancer after 4 years - Increased risk of cardiac event in older users - Increased risk of stroke - VTE -Vaginal bleeding - Breast tenderness

DDX of large ovarian mass

1) benign mass- ie - dermoid 2) Borderline 3) Primary Malignant 4) Metastatic malignant TOA torsion Endometrioma Right sided masses - diverticulutis - appendicitis

when should you perform operative delivery in the oR ?

1- Maternal BMI pre-pregnancy over 30 2- EFW over 4000g or clinical suspicion of fetal macrosomia 3- OP or OT position 4- Mid-cavity delivery

benefits of hormone therapy

- Decreased Hot flashes - Improved symptoms of menopause (joint stiffness, aches, urogenital health (but not uti), -Decreased osteoporosis and fracture - Improvement in depression - Decreased risk colorectal cancer - Sleep - cardiovascular disease (if started early) - Possibly mortality

DMPA

- Depot medroxyprogesterone acetate 150mg IM given every 12 (till 14) weeks, calendar to tell date for next dose - Started any time if sure not pregnant Benefits (non-contraceptive) - Amenorrhea - 60% at 12 month - less dysmenorrhea - less anemia - decreased risk endometrial cancer - Less seizures - Less PID Risks BMD - decreased, but returns to normal after discontinuation Delay in return to fertility - 9months to a year regular menses No impact VTE or MI/CAD Side effects Menstrual disturbance (1st) - especially first few months, - irreg bleeding, heavy in 1-2% Amenorrhea 60% in 12 months - Hormonal symptoms - headaches (2nd) - N/V, decreased libido Weight gain - 2.5kg 1st year, most don't gain weight, appetite stim and anabolic effect Mood symptoms - increased lability but no increased depression in studies

council for fibroid surgery

- Describe abdominal incision, benefits and risks of surgery (infection, bleeding, transfusion, rare risk of hysterectomy) -Impact on fertility from adhesions and tubal blockage Pregnancy -impact on risk uterine rupture - will require cesarean - Risk of recurrence of fibroids and need for further treatment

urodynamic findings of IC

- Early first sensation of bladder filling (< 75 mL) - Decreased volume at first sensation to void (< 200 mL) -Decreased volume at maximum cystometric capacity (< 400 mL) -+/- uninhibited detrusor contractions

sexual assault meds

- Emergency contraception - Hep B prophylaxis if not immune - HIV prophylaxis = Tetanus prophylaxis STI prophylactic antibiotics Abstinence from sexual intercourse until STI prophylactic treatment is completed

cystoscopy findings of IC

- Glomerulations after hydrodistention - Hunner's ulcers - Decreased bladder capacity

causes of painful bladder

- Glycosaminoglycan (GAG) layer deficiency - Infectious cause -Presence of toxic urogenous substance -Immunologic deficiency Neural factors (neurogenic inflammation) Primary mast cell activation in bladder muscularis Multifactorial

hyperthyroid physical exam

- Height, weight, BMI -Vitals - BP, HR, temp, RR - General appearance Nutritional status Stigmata thyroid disease Lid lag, exophthalmos, pretibial myxedema - Nervousness, tremor -Head and neck Nodes Thyroid, nodules or enlargement -Cardiovascular - Respiratory -Abdominal with FH (? Tachycardic) and -SFH -Pelvic

ultrasound findings of congenital varicella

- IUGR - Microcephaly - hydrocephalus - ventriculomegaly -Musculoskeletal abnormalities Asymmetric limb shortening/limb hypoplasia Chest wall malformations - Polyhydramnios - hydrops IUFD

intra-op management of ureteric injury

- Inform anaesthesia - Call for help - urology - Cystoscopy to visualize ureteric jets and place stents - Can use indigo carmine and lasix - may make difficult by staining all tissue blue if you don't recognize injury right away, difficult to sort out multiple injuries - Intraop IVP (rarely used)

diagnostic criteria of PID

- Lower abdominal tenderness - Adnexal tenderness - Cervical motion tenderness - Oral temperature >38.3 degrees celsius Confirmatory tests - laparoscopic visualization of adhesions - endometritis on endometrial biopsy - TOA on ultrasound

what information is needed on surgical pathology

- MRP physician - specimen name/site - collection time - if cancer is suspected - clinical history , if on any meds - Signature

manage GDM pregnancy

- Maintain euglycemia - Maintain appropriate weight gain and adequate nutritional intake - Avoid ketosis (can affect fetal IQ, psychomotor development) - 30 kcal/kg/day as a ballpark - Obese women should have approximately 30% caloric restriction - Avoid weight-reducing diets - Carbohydrate restriction and distribution over 3 meals and 3 snacks, one at bedime - Encourage physical activity

manage pessary discharge

- More frequent pessary removal - Warm-water douching - Replens (moisturizer) - PO metronidazole - PV metronidazole

etiology of infertility

- Ovulatory dysfunction (20-40%) - Tubal and peritoneal pathology - Male factor (30-40%) - Uterine pathology - Unexplained (10%)

what other findings are concerning in microcephaly in brain ?

(cerebral sulcation anomalies, ventriculomegaly, calcifications, haemorrhage, potential signs suggestive of neural tube defect or craniosynostosis)

vaginal bleeding in pessary management

- Pelvic exam to R/O erosion / ulcer vs. bleeding from cervix - Consider EMB +/- TV U/S for PMB if no obvious erosion For vaginal erosion: ● Leave pessary out for 2-4 weeks ● Local estrogen use R/A after 2-4 weeks ● If healed, can resume pessary use, confirm good fit ● If persistent ulcer: biopsy to R/O cancer, although rare

risks for urinary injury in gyne surgery

- Prior pelvic surgery - Endometriosis - Urinary tract abnormalities - History of pelvic irradiation - Obesity - Large pelvic mass - Fibroids, including in the cervix and broad ligament - Large uterus (>250 g) o Previous laparotomy - 2.1 versus 0.5 percent - Previous cesarean delivery - Hemorrhage - Pregnancy - inadequate incision size - suboptimal retraction - poor lighting

apical prolapse surgery

- Uterosacral ligament suspension - Sacrospinous ligament suspension -sacrocolpopexy (hysteropexy or cervicopexy) -McCall Culdoplasty -Lefort partial colpocleisis -Complete colpocleisis +/- concomitant hysterectomy, but NOT hysterectomy ALONE

thrombocytopenia in pregnancy

*< 150,000* Gestational pseudothrombocytopenia ITP - causes for ITP include hep B/C, HIV Preeclampsia Help TTP SLE bone marrow disorders DIC HIT

CAH enzymes

- 21-hydroxylase (90% cases) - 11β-hydroxylase (2nd most common enzyme defect) - 3β-hydroxysteroid dehydrogenase - 17α-hydroxylase

Parvovirus maternal symptoms

- 25% asymptomatic - flu-like illness - low grade fever, malaise, LAD - joint pain, myalgias - slapped cheek rash which spreads to trunk and limbs (onset of rash usually coincides with IgM production suggesting its immune mediated) - myocarditis (rare) - in healthy children/adults usually not an issue (red cell aplastic lasts 7-10days and RBC half life is 2-3months) but more pronounced in patients with underlying hematologic disorders In patients with hemoglobinopathies, parvovirus B19 can cause severe transient aplastic crisis of red blood cells in immunocompromised individuals, pure red blood cell (RBC) aplasia and chronic anemia.

21 hydroxylase deficiency

- 75%: salt-wasting adrenal crises o Require postnatal mineralocorticoids + glucocorticoids - 25 %: simple virilizing type o Sufficient corticosteroid production o Increased androgen levels o Require glucocorticoid supplementation causes hyponatremia hyperkalemia hypotension treat via corticosteroids mineral steroids

hirsutism history

- Age - Work - Ethnicity - HPI: o Duration of this problem o Distribution: face, back, abdomen, inner thighs o Attempted treatments, techniques, #attempts, success o Scalp hair changes o Acne or oily skin o Change in skin color o Change in voice o Chance in breast size o Change in weight (increase muscle mass) - hair loss on head ? o Change in libido - PMHx: o HTN o DM - PSHx - POBHx: GPA status - PGynHx: o LMP o Menstrual irregularity, frequency, amount o Dysmenorrhea o History of infertility o Contraception o STIs - Sexual Hx: o Sexual orientation - FxHx: hirsutism - Meds (steroids, menoxidil, cyclosporine, phenytoin) - All - Habits: smoking, alcohol, drugs

1. List 4 considerations in the OR specific to patients with high BMI (4)

- Anesthesia - might need to do combined spinal epidural - should discuss with anesthesia team - Antibiotics dosing - 3 gram ancef if > 120 Kg - High BMI / wide bed for OR - Exposure - can use self retaining retractors ( traxi/ alexis...) - Difficulty with delivery of fetus - vacuum./ forceps in room - Wound closure and care a. reapproximation of subcutaneous layer b. Consideration for negative pressure wound therapy

manage hemorrhagic shock

ABC's 2 large boer IV's IV crystalloid Vitals Pulse ox foley CBC, ABO, crossmatch PT, PTT lytes , extended lytes liver function, kidney function fibrinogen Vasopressors Then, source control lapartomy IR embolization

screening labs in T1dm

AFP up Hcg down Need to indicate maternal diabetes on rec so adjusted markers

benefits of antenatal magnesium

"death or CP" "death or moderate-severe CP" "any CP" "moderate-to-severe CP" "substantial gross motor dysfunction" (inability to walk without assistance)

infertility physical exam

- Weight, height, BMI, vitals including BP - Thyroid exam: enlargement, nodules, tenderness - Breast: secretions and their characteristics - Signs of androgen excess/insulin resistance: hirsutism, acne, acanthosis nigricans - Abdo/pelvic: tenderness, organ enlargement, mass, uterine size/contour/position/mobility, cervical or vaginal abnormality, secretions, discharge, mass/tenderness/nodularity in the adnexa or cul-de-sac

complete mole ultrasound

- absence of a fetus - no amniotic fluid - enlarged uterus. The uterus is filled with a heterogeneous, predominantly echogenic, mass containing multiple hypoechoic foci in what is commonly described as a "snowstorm" pattern. The uterine mass contains multiple cystic spaces (hydropic villi) resulting in the "cluster of grapes" appearance. As the pregnancy progresses, the cystic areas enlarge and become more numerous. In addition to the cystic spaces, the mass may contain larger irregular fluid collections. In complete hydatidiform moles, ovarian theca lutein cysts may occur when the hCG level is elevated given the ability of the intact hCG molecule to mimic luteinizing hormone.

how often to do viral load/CD4 HIV

- baseline viral load and CD4 - if elevted, can consider doing MONTHLY.... if undetectable, can reduce frequency, but still every trimester at least ..... definitely do around 35-36 weeks

fertility tracking methods

- calendar method (fertile window) - cervical mucus monitoring- highest quality is slippery/clear - ovulation detection devices (ie, LH kts about a day before ovulation) - basal body temperature tracking

treat PID outpatient

- ceftriaxone 250-500mg IM x 1 - Doxy 100mg PO q12 + flagyl 500mg PO q12 x 14 days moxifloxacin 400 mg orally once daily for 14 days Levofloxacin 500 mg orally once daily in combination with metronidazole 500 mg orally 2 times/day for 14 days

Actinomyces on pap

- commensal vagina organism.... BUT may be associated with infection Up to 20% of smears in long-term CuIUD users have it, only 3% with Mirena If asymptomatic, can leave IUD in, follow with annual paps, and warn of sx of PID If symptomatic, treat with doxy, pen G or tetracycline; & remove IUD after preload of antibiotics

when do you refer a patient with hirsutism to endo?

- concern for an endocrine disorder (cushings, late onset CAH) - virilization - androgens very high (2x normal)

PPROM risks to mom and baby

- contributes to 20% of all perinatal deaths - neonates born with chorioamnionitis have increased - sepsis, RDS, seizures, IVH, PVL, CP, death Abruption preterm birth cord prolapse IUFD - maternal risks: sepsis, postpartum endometritis, PPH, cesarean r

necrotizing fasciitis management (nec fasc)

- due to group A strep - infection leading to gangrene of subcutaneous tissue, and subsequent necrosis of more superficial layers - RFs: diabetes, immunocompromised, dirty wound - Clinical features - severe pain, fever, edema, tenderness, crepitus (subcutaneous gas from anaerobes) - infection spreads very rapidly - patients are often very sick and toxic looking - skin turns dusky blue/black (secondary to thrombosis and necrosis) - induration, formation of bullae - Investigations - generally a clinical diagnosis - X-ray - CK (severely elevated) - hemostat easily passed through fascial plane - Treatment - surgical debridement: removal of necrotic tissue, copious irrigation, often repeated trips to OR - IV antibiotics: clindamycin 900 mg IV q8h + Penicillin G 6 Mu IV q4h

complications of intrapartum hysterectomy

- febrile morbidity/infection - coagulopathy/DIC - urinary tract injury (ureteral injury, bladder injury, urinary fistulas) - intestinal injury/obstruction - vascular injury - thromboembolism - postoperative hemorrhage requiring reoperation - death

what OB conditions are associated with hemorrhage ?

Certain clinical conditions and their surgical management are associated with an increased risk of hemorrhage, such as ectopic pregnancy, myomectomy, abruptio placenta, placenta previa, and malignant disease

what causes false positive for VDRL ?

Connective tissue disorders- SLE/ Rheumatoid TB Lulus Hepatitis

Surgical options for SUI

Mid-urethral slings □ Retropubic approach (TVT) □ Transobturator approach (TVT-O, TOT) Pubovaginal slings □ Rectus fascia □ Fascia lata from thigh Retropubic urethroplexy (open or laparoscopic) □ Burch procedure □ MMK (Marshall-Marchetti-Krantz)

sexual assault serology

Pregnancy HepBsAg Hep C Virus Herpes simplex (culture lesion or Serology) VDRL-RPR HIV

hyperthyroid findings

General - thin, tremor, nervous, sweating proptosis lid lad cardiac findings, tachycardia pretibial myxedema weakness hyper-reflexivia

sphylis history

ID: Age GTPAL EDC, LMP HPI: a) Pregnancy: Dating (U/S, LMP), Prenatal labs, U/S, Screening Symptoms of bleeding, cramping, hyperemesis b) Syphilis? - Previously diagnosed/treated for syphilis? o When, where, how dx, how treated - History of genital ulcers o Raised edges with granulomatous base, x 2 weeks - Inguinal lymphadenopathy (non tender) - Rash on palms/soles/trunk - Condyloma lata (warts) - Tertiary syphilis: aortic regurg, iritis, neurological symptoms, gumma (granulomatous lesions) - History of other STI's - HIV status - Immunocompromised - From an endemic population - High risk behaviour: street drugs, sex worker, multiple partners, marginalized population

folic acid factors

1.Genetic factors include: •gene polymorphisms that affect the efficiency of folate metabolism; •DNA methylation/ epigenetics; and •chromosomal anomalies. 2.Environmental factors •dietary folate intake (food fortification and/or dietary supplementation); •gastrointestinal absorption efficiency; •exposure to teratogenic medications, such as antiepileptic or folate-antagonist medications; •problems of glucose metabolism (obesity, diabetes type 1 and 2); and •use of drugs or alcohol. Immune factors include folate receptor autoantibodies that impair folate-related physiological processes and have been associated with NTDs

Congenital syphilis What are ultrasound findings antenatally? What are congenital syphilis findings at birth?

a syphilis infection in a newborn baby resulting from transmission from an infected mother Unlike in adults, initial infection in the fetus is systemic rather than localized. Intrauterine infection results from transplacental and then hematogenous spread of T. pallidum, occurring in: vertical transmission based on stage of disease • 70% to 100% in primary/secondary syphilis • 40% in early latent syphilis • 10% in late latent disease. Ultrasound findings - growth restriction - placentomegaly - hematosplenomegaly - hydrops - polyhydramnios .

maternal complications of breech

a. Deep perineal tears b. Cervical lacerations c. Uterine rupture d. Increased risk of infection e) second stage cesarean- pph, injury

factors predicting renal outcomes

a. Degree of renal function (Cr) b. hypertension

postpartum incontinence questions

a. Solid/liquid stool, consistency of stool b. Is stool loss associated with urgency? c. Pain with intercourse (if attempted) d. Frequency of soiling e. gas incontinecne ?

Thyroid storm presentation

agitation delirium fever diarrhea coma tachyarrhythmia (cause of death) inc ALP due to inc bone turnover

post dates monitoring and management

at least AFI + BPP/ NST 2x a week (start 41 weeks) sweep membranes Instruct on reasons to return - cardinal 4 Preferably, induce, 41 or 41+3

Screen for aneuploidy

eFTS ▪ MA, NT, PAPP-A, free hCG Quad screen in T2 ▪ NT, MA, PAPP-A, AFP, uE3, free/total hCG, inhibin-A NIPT Remember, it is a screen, it is followed up by CVS/amnio

GDM testing gastric bypass

fasting glucose A1C cappilary glucose monitoring

epilepsy labs

normal pre-natal labs DRUG LEVELS (monitor)

minimum pessary changing How often should she be seen in clinic ?

once every 3 months Eval every year

risks of letrozole OI

overall similar, but it does not thin the endometrium as much More common Back pain bone pain hot flashes (sudden sweating and feeling of warmth) joint pain muscle pain Causes high cholesterol fatigue weight gain nausea/vomiting

causes of ICP

previous ICP genetics family hx multiples

anterior vaginal wall mass history

when did it start ? Any pressure ? pain ? bleeding? voiding dysfunction? Stream quality ? dysuria? Urgency? Frequency ? Sexually active? Bowel changes ?

1. What are the indications for pelvic and para-aortic lymphadenectomy?

¨ Histology: Endometrioid grade 2-3, clear cell, serous, squamous ¨ Myometrial invasion ½ (20% nodal metastases) ¨ Cervical isthmus extension (15% nodal mets) ¨ Tumour size > 2 cm (15% risk, if entire cavity, 25%) ¨ Extrauterine disease (pelvic nodes 32%, paraaortic nodes 20%

endometrial carcinoma/ atypia surgery

¨ Peritoneal washings, exploration of the abdomen and pelvis, biopsy of any suspiscious areas ¨ TAH BSO, radical hysterectomy if cervical extension, possible lymph node dissection

risks for ectopic

· IUD · STD/PID · Prev tubal surgery · Use of ART · Prev pelvic/abdominal surgery · Hx ruptured appendix · Prev ectopic preg'y · Smoker

What is the initial management of mixed urinary incontinence?

· SUI: kegels, meds, pessary, PFP, surgery (but first w/u fistula), expectant /5 · OAB: kegels, meds, PFP, BT, decrease caffeine /5

prevent toxo counseling

• Avoid raw or undercooked meat or eggs of any origin • Use gloves when in contact with soil • Wash fruits and vegetables before eating • Avoid changing cat litter, wash hands after handling cats/litter • Keep pet cats indoors and use commercial pet food

OAB treatment

▪ Bladder training ▪ Behavioural modifications: eg. decreased caffeine intake ▪ Vaginal estrogen ▪ Kegels ▪ Medical management: o Anticholinergics o Mirabegron ▪ Biofeedback FES (functional electrical stimulation)

when does the neural tube close

● 3-4 wks embryonic age (5-6 wks from LMP aka GA

consequences of syphilis in pregnancy

● 30% chance of stillbirth ● 10% chance neonatal death ● 40% MR ● 60% congenital syphilis (though 2/3 will be asymptomatic at birth) ● 10-14% preterm labour ● 10-40% growth restriction ● Non immune hydrops

antibiotics for TA

● Antibiotics: o Doxycycline 200 mg PO 30-60 min pre-op/postop or o Metronidazole 1g PO pre-op then 500 mg PO q6h x 3 days ● Dilators: chemical (misoprostol) or osmotic (laminaria) ● NSAIDs pre procedure ● Start an IV line so you can give synto intraop

other anomalies helpful with folic acid

● Cardiac anomalies - OR 0.78 ● Limb defects - OR 0.48 ● Cleft palate - OR 0.76 ● Urinary tract anomalies - OR 0.48 ● Congenital hydrocephalus - OR 0.37

lichen sclerosus consequences

● May lead to distorted anatomy, regression of labia minora, concealment of clitoris obstruction of urethra introital stenosis risk of squamous cell ca

diagnose maternal rubella

1) Serology is most common. Serological studies are best performed within 7 to 10 days after the onset of the rash and should be repeated 2 to 3 weeks later (i.e., acute and convalescent). (similar to CMV) IgM becomes positive shortly after the onset of rash and remains positive for about four weeks 2) NAAT and PCR are useful to confirm rubella infection when IgM test results are equivocal and for surveillance of circulating genotypes. Nasopharyngeal and throat specimens are the ideal samples if collected in the first 5 days after the rash onset...... In addition, viral cultures drawn from nasal, blood, throat, urine, or cerebrospinal fluid may be positive from 1 week before to 2 weeks after the onset of the rash Recent rubella infection is defined as •A 4-fold rise in rubella IgG antibody titres between acute and convalescent serum specimens •Rubella-specific IgG seroconversion OR •A positive serological test result for rubella-specific IgM antibody and low-avidity IgG OR •A positive rubella culture or viral detection via reverse-transcription PCR Even though a positive rubella-IgM result in the right clinical context was traditionally confirmatory of acute infection, positive rubella-IgM antibodies in pregnancy should be interpreted with caution, as false positives occur and occasionally rubella-specific IgM antibodies may persist for months or years after infection or vaccination. Since false-positive results are becoming relatively more frequent as rubella incidence declines, it is important that a positive rubella-IgM result in a pregnant woman is thoroughly investigated using other confirmatory tests such as paired IgG (acute and convalescent), IgG avidity, or rubella virus isolation by culture or NAAT, to avoid unnecessary terminations of pregnancy.

cocp mechanism

1) Suppresses ovulation (estrogen FSH, progesterone LH) 2) Thickens cervical mucus to prevent fertilization/Impede sperm (progesterone) 3) Endometrial atrophy (progesterone, stabilized by estrogen and sensitizes cells to progesterone with increased intracellular progestin receptors) 4) Decreases tubal motility to inhibit ovulation/oocyte transport Lipids - overall estrogen effect from combined OCP's Estrogen: Increased HDL, increased trilycerides, decreased LDL Progesterone: decreased HDL, increased LDL (especially androgenic ones) Coagulation - again, due to estrogen Increased fibrinogen Increased factor V, VII, VIII, X Increased plasminogen and protein C Decreased antithrombin Decreased protein S/C ratio

thickened NT workup

1) genetic counselling - referral to MFM 2) invasive testing (CVS or amnio) 3) NIPT ( if declines invasive/diagnostic testing ............................................................___/1 4) early anatomy scan if available 5) detailed anatomy scan 6) fetal echo

treat the following: 1) hypogonad hypogonadism 2) PCOS 3) POI

1) ovarian stim with Gonadotropins Weight gain Ovulation induction - 2) Clomid/femera Metformin IVF 3) POI- donor eggs

where can the ureter be injured in gyne surgery?

1) pelvic brim, near the IP ligament 2) Underneath the uterine 3) lateral pelvic sidewall, especially if lymph node dissection 4) near the bladder- closing vault

HiV viral load delivery

1,000- SVD, > 1,000- cesarean Test around 34 weeks.... if above 1,000, do C/S at 38w Gize zidovudine (AZT) before a C/S for 3 hours before surgery (2 mg/kg for 1 hour, then 1 mg/kg/hour until delivery) AZT may not be needed for labor if viral load is <1,000.... but, not wrong to give. CONSIDER giving ¨ Single dose neverapine 200 mg if detectable viral load or no antepartum antiretrovirals

decrease of risk of vacuum trauma

1- Avoid excessive, incorrect, prolonged application (over 15min), pop-offs and no rotation with the vacuum cup. appropriate suction

ovarian cancer surgery

1. · COMPREHENSIVE SURGICAL STAGING · Midline laparotomy · Peritoneal washings · Inspection: abdominal / pelvic surfaces 1. Diaphragm, liver, spleen, stomach, kidneys, pelvic-periaortic nodes, omentum, run-the-bowel, uterus/tubes/ovaries · TAHBSO - send for frozen section · Retroperitoneal lymphadenectomy (pelvic, periaortic nodes) · Infracolic omentectomy · Bilateral diaphragmatic scrapings / biopsies · Perotoneal biopsy · Biopsy: suspicious nodules / adhesions /

investigate hydrops

- fetal ultrasound for anomalies, other causes (twins, hydrothorax, arrhythmia) - MCA doppler (for anemia) - fetal echo Labs - blood type and antibody screen (indirect coombs)- this is for IMMUNE hydrops - hemoglobinopathy screening - Kleihauer - ToRCH/B19/syphilis serology AMNIO - fetal karyotype - TORCH, B19 , hemoglobinopathy The initial testing of the mother should include the elimination of immune causes of hydrops with blood typing and the indirect Coombs test. If the standard indirect Coombs test done by the blood bank is negative, but there remains a strong suspicion of isoimmune hemolysis in a multiparous couple, then the blood bank should be asked to run a Coombs cross-match with maternal serum and paternal red cells to detect an uncommon or "private antigen" mismatch. A screen for hemoglobinopathies, a Kleihauer-Betke test to look for fetal red blood cells in the maternal circulation, and titers for syphilis, parvovirus, and the TORCH infections (toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex) should be done. Some of these tests may not be immediately available, but blood should be drawn and sent to the laboratory. A fetal karyotype should be obtained in most cases. With the availability of fluorescence in situ hybridization, the major aneuploidies (trisomies 21, 18, and 13, and monosomy X) can be rapidly detected in amniotic fluid cells. If infection is suspected, amniotic fluid and maternal blood should be sent for polymerase chain reaction testing or culture.

Routine steps for breech delivery

- insert IV - good analgesia - continuous EFM on both - have anesthesia, 2 NICU providers for resess - insert foley Ideally in center with ability to perform a CS, attendant skilld in breech Passive second stage of 90 mins imminent delivery in 60 mins PPH kit oxytocin ultrasound Pipers Scissors- durschden's Start oxytocin after first twin delivers Hands off as much as possible - pinard - loveset - smellie Veit - ?prague

types of vaccines

- live attenuated - inactivated/killed - toxoid - conjugate - mRNA

complications of cerclage

- local bleeding - infection - damage to surrounding structures (ie, bladder) -ROM - anesthesia risks -failure

fetal risks of hyperthyroidism

- mainly due to the passage of stimulatory or inhibitory thyroid antibodies across the placenta, poorly controlled maternal disease - Fetal thyrotoxicosis - 1% Tachycardia, - IUGR - hydrops - stillbirth - goiter SA, preterm birth advanced bone age Craniosynostosis, anomalies Increased perinatal mortality

risks for GDM

- maternal age of >30 - BML >25 - PCOS - cushing - acromegaly - family history of type II - obstetric history (infant more than 9 pounds, hydramnios, unexplained stillbirth or abortion, infant with congenital anomalies) - ethnicity (ie, Asian, aboriginal, black) - meds (ie, corticosteroids) b

IUFD causes

- maternal causes - GHTN, GDM/DM - heart disease - cholestasis of pregnancy - hemoglobinopathy - previous sensitized pregnancy (anti-D) - trauma - epilepsy - clotting disorder/APA syndrome, SLE - autoimmune disease - infection (TORCH) - post-term pregnancy - uterine rupture (prev C/S) - drugs: smoking, cocaine - fetal causes - congenital/chromosomal anomalies - multiple gestation - IUGR - placental causes - abruption (acute, chronic) - TTTS - cord accident - previa - chorioamnionitis - placental abnormalities (knots, small/large, lakes)

what reduces success of ECV ?

- nulliparity (most consistent factor associated with failure) - oligohydramnios (2nd most important factor is amniotic fluid) - anterior placenta - ant/post position of fetal spine - tense uterus - engaged head - obesity - Uterine anomalies Higher success if : - transverse lie - multips - good fluid - posterior placenta - non-obese - not engaged continuous EFM is recommended

colpoclesis candidates

- older - not sexually active - advanced prolapse (procidentia)

indications for surgery in PID

- peritonitis (ruptured abscess with sepsis, hemorrhage) - failed medical management (after 48 hrs of antibiotics) - large TOA not amenable to CT-guided drainage - atypical presentationbb

risks for PID

- prior PID - multiple partners - New partner - Not using condoms - STI or other genital infection - Recent genital tract procedures (hysteroscopy, IUD insertion) -

reduce blood loss at fibroid surgery

- shrink it before surgery (lupron) - pre-op misoprostol - Uterine tourniquet - Bulldogs on the - Vasopressin -

how can OCP's help hirsutism?

- suppress GnRH - reduce ovarian androgens - diane-35 has an anti-androgen specifically - increases SHBG

things to discuss at the time of EC

- testing for other STI's, HIV, syphilis, GC, trich, BV, hepatitis - discuss imporance of long term contraception - discuss importance of condoms Full health history - pmhx, social hx, - ensure no substance use, social concerns

reaons you would not transfer a TPTL

- unstable patient - imminent delivery - abnormal FHR Poor weather - no availablility of provider

risks of RR BSO for BRCA

---short term side effects : surgical menopause-- abrupt onset of menopausal symptoms (Hot flushes, insomnia, anxiety, depression) ----Long term effects: decreased bone mineral density, decreased libido, vaginal dryness, cardiovascular risks ---recommend DEXA 1-2 yrs after BSO

causes of post menopausal bleeding

--urogenital atrophy - endometrial atrophy --polyps - fibroids --endometrial hyperplasia --endometrial cancer - cervical polyps, irritation

PMB causes

--urogenital atrophy --polyps (cervical or uterine) - fibroids --endometrial hyperplasia --endometrial cancer - unknown

risks for endometrial cancer

-Advancing age -nulliparity -early menarche, late menopause - anovulation - PCOS - diabetes - hormone therapy - tamoxifen - family Hx - lynch syndrome - liver disorders

when to seek medical care for IUD ?

-Can't feel strings -She or partner feel end of IUD -Thinks she's pregnant - Persistent abdo pain, fever, or unusual vaginal discharge -Pain during intercourse --Wishes to remove IUD _wishes to conceive - when duration is up (10 years copper, now up to 8 for Mirena) - Sudden change in menstrual pattern

ovarian reserve testing

-Day 3 FSH (> 14) -low AMH - antral follicle count (follicles 2-10mm)

elective CS ERCS benefits

-No chance of uterine rupture - avoids emergency CS - convenience, know the dates - urogyne benefits

risk factors for VTE

-Obesity -excessive blood loss -known thrombophillia (APS, factor V) -long OR -poor mobility -Infection - chronic disease Malignancy Pregnancy- post partum especilly Family hx previous VTE

what are indications for classic CS

-Placenta accreta spectrum - especially if previa with anterior attachment -Prior radical trachalectomy for cervical cancer - Active cervical cancer -Poorly developed lower segment (eg generally under 28w GA or with SGA fetus in breech presentation) - Lower segment unsafe to access - eg. dense bladder adhesions, lower segment fibroid, extreme maternal obesity Fetal: Transverse lie of a large fetus Back down transverse lie Small and breech Multiple fetuses

Accreta on ultrasound

-Placenta previa - thin myometrium (<1mm) - loss of hypoechoic retroplacental space - - numerous (3+) large lacunae w/ "moth eaten" appearance of placenta - exophytic mass of tissue beyond uterine wall Color - hypervascularity between myometrium and posterior wall of bladder subplacental hypervascularity - lacunae feeding vessels with high velocity flow (>15 cm/s, turbulent) from arterial vascular of myometral lakes

risks for peripartum cardiomyopathy

-Previous peripartum cardiomyopathy - underllying heart condition - older age Age > 30 - History of PET, eclampsia, or PP HTN ● Obesity ● Anemia ● Infection ● Multiparity ● African descent ● Maternal cocaine abuse ● Multiple pregnancy

risks for ureteric injury

-Prior pelvic surgery - adhesions, endometriosis - cesarean sections - distorted anatomy - large fibroids - bleeding /hemorrhage - hx of radiation - obesity - poor lighting, visualization

non classic CAH

-Pt's retain greater 21-hydroxylase activity -Sx arise later in life -Pt's require glucocorticoid tx to help reduce ACTH and androgen levels causes - hirsutism, acne, infertility, irregular menses Measure 17-OHP confirm by ACTH stim test

steps to manage perforation

-Stop the procedure - inform anesthesia - Remove all instruments -Antibiotics IV Treat according to the type & location of the perforation ● Fundal with blunt instrument o Observe the patient for 24-48h o VS & Hgb monitoring o If signs of acute abdomen or hemorrhage 🡪 laparoscopy ● All other perforation: o Immediate laparoscopy o Antibiotic o Irrigation - apiration of all distension fluid o Look for vascular, intestinal or bladder injury and treat accordingly Always remember to disclose to the patient

Cystocele exam

-Visual inspection for atrophy -S2-4 neurological exam (bulbocavernosus and anal wink reflexes) and perineal sensation -Cough stress test supine +/- standing with full bladder (and with prolapse reduced) -Urethral hypermobility with Q-tip test (>30 degrees is positive) -Split-speculum exam for prolapse stage assessment -Assessment of paravaginal defect for anterior prolapse -Levator tone/strength -Bimanual exam

next pregnancy after molar pregnancy

-an early ultrasound scan is recommended to confirm a normal intrauterine pregnancy. At the time of delivery - the placenta should be carefully examined and sent for pathology if there are any clinical abnormalities. -In the event of an ectopic pregnancy or abortion of any type, the products of conception should be sent for histologic examination. - hCG 6 weeks post partum

risk of breech during L&D What is the acid base abnormality ?

-asphyxia from cord compression..... Breech infants are often depressed at birth due to respiratory acidosis secondary to cord compression during expulsion. A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery. Higher risk of - mortality - neurologic injury, serious short term (no major long term) - needing resus, NICU admission, low APGARS - cesarean (with risks of cesarean)

hirsutims investigations

-bHCG - FSH, LH, estradiol -TSH, PRL - Testosterone (total and free), DHEA-S, androstenedione - 17OHP - fasting glucose, insulin, HbA1C, 75gOGCT - fasting lipids - possibly screen for Cushing syndrome- 24 hour urine for cortisol -pelvic ultrasound - endometrial biopsy - for no period for one year at ANY time - consider MRI/CT if adrenal tumor if suspected

what contraceptive options are available in CAT 3/4 WHO people ?

-barrier methods -IUD/IUS -progestin-only pill -Depo-Provera -Nexplanon -tubal ligation -vasectomy

OHSS return to care instructions

-call/report for care if: rapid weight gain/2lbs per day, abdominal circumference increase 1 inch/day, decreased urinary frequency, worsening abdominal pain, SOB, leg pain or swelling

endometriosis consequences

-dysmenorrhea -- Bowel pain - bladder pain - painful intercourse -Pelvic pain -Infertility -Slight risk of cancers (endometrioid, clear cell) -ectopic pregnancy

risks for endometriosis

-family history -early menarche -late menopause -heavy/frequent menstrual bleeding - nulliparity - mullerian/outflow anomalies -

consequences of OASIS

-fecal urgency (26%) -perineal pain (9%) -wound infection (8%) -incontinence of gas or stool (up to 10%) -rectovaginal fistula (rare)

risks of uterine inversion

-fundal placenta - uterine atony -excessive traction on the umbilical cord before placental separation -abnormally adherent placenta.

indications for C/S with HIV

-high viral load >1000 -unknown viral load -untreated HIV -treated with only monotherapy vs triple therapy -

requirements for assisted vaginal delivery

-informed consent -fully dilated -ruptured membranes -Vertex presentation (except pipers with head entrapment with breech) - head engaged -experienced operator --adequate analgesia - ability to do C/S - NICU

ways to diagnose endometriosis

-laparoscopy + biopsy/pathology - clinical suspicion - imaging (ultrasound + MRI)

indications for assisted vaginal delivery

-maternal exhaustion -maternal conditions that preclude pushing (cardiac disease, severe respiratory disease, spinal cord injury) - abnormal fHR - prolonged second stage of labor - correct fetal malposition

whne to do UTI cysto

-non e-coli infection - persistent hematuria - structural anomalies - consider with complicated infection - stones

risks of IVF

-risk of multiples-->multiple embryos often transferred -Maternal: ovarian hyperstimulation syndrome, complications from egg retrieval, C-section, preeclampsia Fetal risks -premature birth, low birth rate, congenital malformations (cardiac) , other long term effects

indications for hospitalization OHSS

-severe abdominal pain or peritoneal signs -intractable N/V and unable to keep anything down -oliguria/anuria -tense ascites -dyspnea or tachypnea -hypotension, dizziness or presyncope -electrolyte imbalance (Na < 135, K>5) -hemoconcentration (Hct > 45%) -elevated creatinine over 120 -elevated transaminases

when would you do thyroidectomy in graves What are complications?

-severe hyperthyrodim refractory to treatment - severe reaction to treatment (ie, agranulocytosis) - enlarged thyroid causing airway obstruction Complications - thyroid storm - hemorrhage - recurrent laryngeal nerve injury - hypoparathyroidism

factors with unsuccessful pessary fitting

-short vagina <6cm -wide introitus >4cm - lower initial prolapse -Younger age -rectocele -previous vaginal surgery - stress incontinence

maternal risks of preeclampsia

-stroke -eclampsia -reversible cereberal vasoconstrictive syndrome - MI - aortic dissection - AKI - liver subcapsular hematoma and intraparynchymal hemorrhage _ bleeding disorders, bleeding - Fetal - death - growth restriction - preterm birth - abruption

DDX of uterine inversion

-uterine inversion - could be an accreta - cervical prolapse vs uterine prolapse

Define asthma

. Chronic inflammatory airway disease characterized by: ● Reversible airway obstruction from bronchial smooth muscle contraction ● There is an "irritant / allergic / hypersensitivity component" to the airway inflammation

SOGC previous stillbirth induction

. Decisions around timing of birth should incorporate the circumstances surrounding the previous stillbirth, the clinical picture of the current pregnancy, and the emotional state of the woman and her family, while taking into account the known drawbacks of birth prior to 39 weeks. In select cases, there may be a role for early term (37-39 weeks) birth. There is no evidence for delivery before 37 weeks based on the risk factor of stillbirth alone (GRADE: moderate).

normal signs of asthma

. Mild wheezing A. Dyspnea B. Increased respiratory effort C. Chest tightness D. Breathlessness

1. What are the common irritants that exacerbate asthma?

. Viral infections A. Cold B. Irritants: dust, animals, cigarette smoke C. Aspirin D. Exercise

first trimester bleeding labs

. What investigations do you order: ¨ BHCG ¨ +/- progesterone ¨ CBC ¨ G&S ¨ If suspect ectopic add LFTs, renal function Pt/INR

4 categories of contraception

1 = A condition for which there is no restriction for the use of the contraceptive method. 2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks. 3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method. 4 = A condition that represents an unacceptable health risk if the contraceptive method is used.

antiphospholipid antibody criteria

1 of 2 clinical criteria PLUS lab criteria Clinical: 1. History of arterial or venous thrombosis confirmed on imaging or pathology 2. Pregnancy complications - one or more unexplained fetal death at 10 weeks of gestation or more of a morphologically normal fetus - one or more preterm birth(s) prior to 34 weeks due to preeclampsia or placental insufficiency - three or more unexplained embryonic losses at less than 10 weeks gestation Lab: (2x, 12 weeks apart) 3. Anticardiolipin antibody (medium to high titres of IgG or IgM) 4. Lupus anticoagulant 5. B2 glycoprotein

when to evaluate infertility

1 year unprotected intercourse 6 months if: - age > 35 without delay in -hx oligomenorrhea or amenorrhea - known uterine or tubal disease - known stage 3/4 endo - known/suspected male infertility Women in need of donor sperm to achieve pregnancy

when can perforation occur ?

1. At cervical dilation 2. Uterine sounding 3. When the scope comes in contact with the uterine fundus 4. With resection: o Synechia o Septum o Fibroid o Endometrium

primary amenorrhea causes

1) Anatomic defects (outflow tract) - Mullerian agenesis (MRKH) - Imperforate hymen - vaginal septum - cervical agenesis or stenosis - Genetic causes - Swyer syndrome (46 XY) - Turners/ mosiac (45 XO/46XX) - AIS (46 XY) A. Gonadal dysgenesis C. Enzymatic deficiency (17a-Hydroxylase deficiency, aromatase deficiency) D. Premature ovarian failure 1. Idiopathic 2. Injury a. Chemotherapy b. Radiation c. Mumps oophoritis 4) auto -immune- anti adrenal III. Hypothalamic causes A. Dysfunctional 1. Stress 2. Exercise 3. Nutrition-related a. Weight loss diet, malnutrition b. Eating disorders (anorexia nervosa, bulimia) Isolated gonadotropin deficiency a. Kallmann syndrome b. Idiopathic hypogonadotropic hypogonadism 2. Infection a. Tuberculosis - sarcoidosis Pituitary causes - prolactinoma - other pituitary tumors Other endocrine gland disorders A. Adrenal disease 1. Adult-onset adrenal hyperplasia 2. Cushing syndrome B. Thyroid disease 1. Hypothyroidism 2. Hyperthyroidism C. Ovarian tumors 1. Granulosa-theca cell tumors 2. Brenner tumors 3. Cystic teratomas 4. Mucinous/serous cystadenomas 5. Krukenberg tumors 3. Nonfunctional tumors (craniopharyngioma) 4. Metastatic carcinoma B. Space-occupying lesions 1. Empty sella 2. Arterial aneurysm C. Necrosis 1. Sheehan syndrome 2. Panhypopituitarism D. Inflammatory/infiltrative 1. Sarcoidosis 2. Hemochromatosis 3. Lymphocytic hypophysitis E. Gonadotropin mutations (FSH) VI. Multifactorial causes A. Polycystic ovary syndrome

when is risk of anal compromise after endoanal US or mamometry

1) EAS defect > 30 degrees with max squeeze pressure of <20 2) eas defect < 30 and MSP of <20

dating a pregnancy

1) Earliest scan where there is either - 7 weeks GA - 10mm CRL - 84mm 2) When the CRL is greater than this length, other biometry indices can be used (HC, BPD, AC, FL) 3) dates (Naegle's rule ) subtracts 3 months and adds 7 days to calculate the estimated due date (EDD) 4) cerebellum

fibroid management

1) Expectant management a. Definition of the diagnosis and possible course if not addressed with continued heavy menses and potential impact on fertility b. Including iron supplementation 2) Medical treatment a. NSAIDs (Ibuprofen, Naproxen) b. Tranexamic acid (Dosage 500 mg 1-2 tabs PO q6-8 hrs with menses) c. Potential use of OCPs or levonorgestrel IUS with limited success Procedural - endometrial ablation - Uterine fibroid embolization but not recommended considering wishes of future fertility and limited studies regarding UFE and fertility and reduced ovarian reserve - high resolution ultrasound Surgical - myomectomy (open or laparoscopic) - hyst

unexplained infertility treatment

1) Expectant management. - reasonable option to keep trying in couples with good prognosis 2) Laparoscopy not warranted for evaluation, UNLESS a) there is some evidence of tubal or other pelvic pathology on ultrasound or HSG b) there has been a long time (>3 years) of unexplained infertility c) IUI alone do not offer natural cycle IUI, no benefit d) ovarian stimulation alone (oral or gonadotropins) In unexplained- letrozole or clomid are not helpful (obviously, it is helpful if not ovulating) 3) gonadotropin-OS (ovarian stim) alone there is insufficient evidence to recommend this in the management of UEI 4) SO-IUI w/ oral Super-ovulation with letrozole/clomid PLUS IUI is effective, first line treatment 5) SO-IUI w/ gonadotropins higher pregnancy rate per cycle (and a higher multiple pregnancy rate per cycle) than IUI with oral agents also better than gonadotropin alone 6) IVF IVF is the best. It may reduce multiple pregnancy rates compared to FSH-IUI (single transfer) IVF should be offered to couples with UEI after three cycles of ovarian stimulation/IUI have failed 7) IVF w/ ICSI There is insufficient evidence to recommend the routine addition of ICSI in couples with UEI undergoing IVF to increase the live birth rate, although the addition of ICSI in IVF for UEI may reduce the incidence of total failed fertilization (TFF)

SOGC MgSO4 recommendations

1) For women with imminent preterm birth, antenatal magnesium sulphate for fetal neuroprotection should be administered as a 4-g intravenous loading dose, over 30 minutes, with or without a 1g per hour maintenance infusion until birth (II-2B). This is recommended because it is the mean time from starting Mag to delivery :/ 2) For planned preterm birth for fetal or maternal indications, magnesium sulphate should be started, ideally within 4hours before birth, as a 4-g intravenous loading dose, There is insufficient evidence on re-retreating.... but be reasonable to re-treat women who present again with imminent preterm birth if magnesium sulphate were last administered 12-24hours prior, based on a maternal serum half-life of magnesium sulphate of 4hours and evidence that suppression of maternal cytokine production is an important neuroprotective mechanism Close monitoring of maternal urine output should not be required to the same degree (i.e., no requirement for Foley catheter) when magnesium sulphate is given with neuroprotective intent.

GT vs ITP

1) GT does not respond to IV immune globulin (IVIG) or corticosteroids, which has been tried when thrombocytopenia is so severe as to compromise epidural anesthesia or delivery 2) thrombocytopenia does not resolve within 1 to 2 months of delivery, the diagnosis of ITP or HT may become evident only in hindsight. 3) Level - GT is rarely below 100, almost never below 70 4) Timing- GT happens later in pregnancy (mid second trimester or later) 5) Baby may have ITP 6) ITP- may have hx of bleeding

causes of hydrops

1) Genetic causes - o Most common is 45X o Others include trisomy 21, 13, 18, 12, tetraploidy and triploidy 2) Cardiovascular - structural (hypoplastic left heart, tetralogy of fallot, aortic stenosis, pulmonary stenosis) - arrhythmia (SVT, VT, heart block) 3) Thoracic abnormalities - CPAM - diaphagmatic hernia 4) Anemia - infectious, bleed, hemoglobinopathy 5) Infectious - B19, TORCH, syphilis 6) Twins TTTS

DKA pregnancy investigation What lab derangements would you see?

1) History 2) Physical exam - check for dehydration like mucus membranes, cap refill - sources of infection (listen to heart, lungs, CVA tenderness) - vitals CBC Pan culture for infection (blood culture, urine analysis + culture, CXR) labs CBC, electrolytes serum glucose anion gap Urine ketones and serum ketones lactate Bicarb ABG or VBG (probably ABG, consider ART line) liver function, kidney function Fetal monitoring Labs- defined by: - high glucose (>250) ... though may be lower in pregnancy - serum ketones (>3) - urine ketones (+2) - acidosis (<7.3) serum bicarbonate is ≤15 mmol/L the anion gap is >12 mmol/L

contraindications to hysteroscopy

1) IUP 2) confirmed cervical or endometrial cancer 3) Pelvic inflammatory disease, 4) active genital herpes 5) uterine perforation

types of hirsutism

1) Idiopathic (no cause) 2) Hyper-androgenism 3) normo- androgenism Most common is PCOS (hyper-androgenism)..... then idiopathic Idiopathic- all normal, normal menses Hyperandrogenism - PCOS (mild DHEAS/ androstenedione) - androgen secreting tumors (very high DHEAS / androstenedione) - CAH (high 17 OHP) (morning, follicular) - Acromegaly nono-androgenism -Cushing Syndrome -Acromegaly -Drugs/meds What is your differential diagnosis of this patient's hirsutism - PCOS (most common) - Meds (danazol, anabolic steroids, valproic acid, CC, tamoxifen, phenytoin, interferon) - Ovarian/adrenal tumour (usually virilization; adrenal carcinoma, Sertoli-Leydig, granuloma cell, thecoma, gonadoblastoma) - Cushing's - Adult-onset adrenal hyperplasia (partial 21-hydroxylase def) (non-classical CAH) - Idiopathic (↑5α reductase activity) - Mild hyperprolactinemia - Luteoma of preg. theca-lutein cyst - HAIR- AN (hyperandrogenic insulin resistance, acanthosis nigricans) - Acromegaly (frontal bossing, incr hand/foot size, mandibular enlargement, hyperhidrosis)

pneumococcal indications

1) Immunocompetent host with major medical issues like chronic heart disease, chronic lung disease 2) persons without a spleen, or sickle cell 3) immunocompromised - HIV, cancer, taking immunosupressants

indicatious for assisted vaginal delivery

1) Maternal diseases maternal cardiac disease (New York Heart Association class III or IV), severe respiratory disease cerebral arteriovenous malformation proliferative retinopathy, as well as neurologic diseases such as: - myasthenia gravis - spinal cord injury at risk of autonomic dysreflexia. 2) Abnormal FHR 3) delayed second stage 4) Maternal exhaustion

indications for cerclage

1) Obstetric history-based diagnosis — history of 1+ second-trimester pregnancy losses or extremely preterm births associated with no or minimal mild symptoms...... The presence of risk factors for structural cervical weakness supports the diagnosis. Most of these cases are pregnancy losses before 24 weeks. Put in late first tirmester (12-14 weeks) 2) Ultrasound-based diagnosis — In asymptomatic patients with a past history of 1+ extremely preterm birth associated with no or minimal mild symptoms .....we perform serial TVU examinations and make a diagnosis of cervical insufficiency when CL is ≤25 mm before 24 weeks (typically 16-24) Unknown if cerclage is of benefit in short cervix <25mm without hx of PTB 3) Physical examination-based diagnosis — We make a diagnosis of physical examination-based cervical insufficiency in patients at 16 to 24 weeks of gestation with a dilated and effaced cervix on physical examination and no contractions or weak irregular contractions that appear inadequate to explain the cervical dilation and effacement. The membranes may be prolapsed or ruptured. Labor, infection, and bleeding related to placental abruption or placenta previa should be excluded

what other locations can you use for pneumoperitoneum

1) Palmer's point (3 cm below the left subcostal margin in the mid-clavicular line.) 2) suprapubic at the uterus 3) Lee Huang point - midway between the xiphoid process and the umbilicus along the midline

You have been called to triage to assess a 24 G5P2 with vaginal bleeding and cramping. The following history has been provided to you by the clerk on the service: The patient appears to be pregnant in the second trimester and has complaints of nausea, vomiting, diarrhea, and diffuse achiness for several hours. She has also had abdominal cramping and had some slight vaginal bleeding in the last hour. Her last period was 5 months or so ago. She smells of cigarette smoke and is somewhat unkempt. WHat do you want to know on HX

1. Candidate should ask these questions as part of focused history: Onset duration of pain/bleeding ................................................... ___/1 Complications in this pregnancy/Early US/T2 US .............................. ___/1 Chronic or acute medical problems ............................................... ___/1 Medications/allergies ............................................................... ___/1 Social or recreational drugs- and method of administration .................. ___/1 HIV, hepatitis A, B, C status ...................................................... ___/1 Family history of substance dependence ......................................... ___/1 Family history of psychiatric illness .............................................. ___/1 Who lives at home with you? Are they using drugs? .......................... ___/1 History of domestic or sexual abuse .............................................. ___/1 Confirm that kids are not living with her- if she has access to care for them, then CAS will need to be called ................................................... ___/1 1. Have you ever used cocaine, marijuana or any other recreational drug? (Opiates (heroin), stimulants (ecstacy), inhalants, hallucinogens, designer drugs) Injecting drugs? Sharing needles? Sharing straws?............................ ___/1 Are these drugs prescribed by a doctor or not?................................... ___/1 Ask about use in other pregnancies, including alcohol ......................... ___/1 Any developmental delay in the other children? ................................ ___/1 Any CAS involvement? ............................................................

surgical shock management

1. Laparotomy as unstable 2. Surgical backup (experienced gynecology surgeon, general surgery) 3. Anaerobic and aerobic cultures of peritoneal fluid and abscess cavity 4. Careful dissection as surgery can be technically difficult as anatomic distortion secondary to inflammatory response, adhesion formation 5. Debriding necrotic tissue 6. Copious irrigation of peritoneal cavity 7. Close fascia with monofilament delayed absorbable suture Consider leaving skin and subcutaneous wound open for at least the early postoperative period - delayed closure or healing by secondary intent (no direct evidence vs. direct skin closure) 8. Leave in closed suction drain (e.g. Jackson Pratt) Question 9: The surgery is complete. Outline the immediate postoperative care. ICU admission Lines stay in situ Continue IV antibiotics Debrief with patient and family members

what to do if uterine inversion fails ?

1. Large bore IV 2. Anaesthesia 3. Additional Gynecologist 4. Move to an operating room 5. Monitor vitals and blood loss 6. Cross match for blood If manual repositioning is unsuccessful by a vaginal approach, laparotomy or laparoscopy may be indicated to correct this condition. Two procedures have been described for these circumstances. 1) The Huntington procedure involves serial clamping and upward traction on the round ligaments to restore the uterine position. 2)The Haultain procedure, the cervical ring is incised posteriorly to aid in repositioning of the uterus. Both procedures are then followed by uterotonic therapy.

Diagnose Syphilis

1) Previously- direct visualization of spherocytes- ie, dark field microscopy Usually screen with Nontreponemal tests include RPR or VDRL But, these can have FALSE NEGATIVES with PRIMARY syphilis, due to time to seroconvert and produce antibodies (as well as false positives for RPR, ie, SLE, HIV). in patients who have reactive VDRL or RPR results....Then, Treponema-specific tests are used to confirm the diagnosis of syphilis (FTA-ABS or Trep-pallidum particle agglutination assay aka TP-PA Recently, a different sequence of testing for syphilis has been described. In this testing algorithm: - the initial test is an enzyme immunoassay, for IgM and IgG antibody a) If this test is negative, no further testing is indicated. b ) If it is positive, then a quantitative RPR is performed. (for RPR titers) - If the RPR is negative, then the TP-PA assay is performed. A negative TP-PA assay indicates that the patient is uninfected. A positive test confirms that the patient is infected, but it remains positive and therefore does no distinguish precisely between acute versus chronic infection. Therefore, in my opinion, the conventional testing sequence using the VDRL or RPR, followed by the FTA-ABS or TP-PA, remains preferable. RPR titers should be monitored and they correlate with disease activity It is critical to recognize that when the syphilitic chancre first appears, both the nonspecific test results and the treponemal-specific test results may be nonreactive. Therefore lesions suspicious for syphilis should be sampled for detection of spirochetes and submitted to the laboratory for dark-field examination and fluorescent antibody staining.

nerve injuries at laparoscopy

1) Sciatic nerve: from sharp/excessive hip flexion or external rotation 2) Common peroneal nerve nerve: from compression at the lateral head of the fibula 3) Peripheral ulnar nerve: from external compression of the elbow when the arm is tucked 4) Brachial plexus: from hyperextension of the upper extremity 5) femoral nerve

varicella exposure by trimester

1. Look at booking blood and check if she is immune!!! If IgG positive, nothing to be done. If negative, nothing to be done!! However, in settings where pregnant women might be tested too late and/or results may not be available quickly, using VZIG before antibody testing results are available might be practical. 2 If under 20 weeks,, this is a risk because the fetus is still developing"..... so must advise a 2% risk baby will get congenital varicella syndrome which is devastating!!!!!!!!!!!!* - Give varicella zoster immunoglobin....... Bring mother into side room away from sick people and pregnant women, and give injection. Follow on ultraround. If the exposure is early, consider amnio for fetal exposure .... maybe MRI 1) If OVER 20 weeks, there is no risk of congenital varicella...... BUT, pregnant women are immunosupresed, and VZV has a very high risk of causing pneumonia, and high risk of morbidity and mortality, and 10% need intubation...... so *still get varicella IgG for maternal benefit!!!* If women get ANY viral illness in pregnancy they get high fever, and high fever is risk of preterm labor!!!!!!!!!!!!!!! 3) At 39 weeks, and the Chickenpox infection occurs within 5 days of delivery......* give BOTH the mom Varicella IgG... AND give the baby varicella igG.* 4) If pregnant women DOES have chickenpox (rashes evident),, you do NOT give the vz-IgG - admit them - isolate them - give IV acyclovir

neonatal herpes What are the three levels?

1. Skin/eye/mouth- rarely fatal, but still a risk of neurologic (encephalitis) 2) central nervous system disease (manifested as encephalitis with or without skin, eye, and mouth infection) 3. disseminated disease (the most serious form of infection, which has a 90% mortality rate if untreated) The risk for neonatal infection seems to be greatest when maternal primary infection occurs in the third trimester. In this situation, the mother acquires infection but is unable to complete seroconversion to IgG prior to delivery, and the infant is delivered in the absence of protective passive IgG from the mother. In this case, there is a 30% to 50% risk ofneonatal herpes infection Neonatal HSV causes disseminated or CNS disease (seizures, lethargy, irritability, tremors, poor feeding, temperature instability, and bulging fontanelles) in approximately 55% of cases. Up to 30% of infants will die and more than 50% can have neurologic damage despite antiviral therapy. The classic triad is - skin lesions -chorioretinitis -CNS abnormalities. In all cases of suspected neonatal or congenital HSV infection, an early consultation with a pediatrician or pediatric infectious diseases expert is highly recommended. Intravenous antiviral therapy (acyclovir) should be initiated as soon as possible as per standard dosing guidelines. There is evidence of significant reduction in mortality(from 58% to 16%) and neurologic sequelae with its use Studies had suggested that primary infection occurring in the first or second trimester caused an increase in spontaneous abortion and/or prematurity and fetal growth restriction.....However, more recent series have not confirmed these findings. in rare cases, there is trans-placental transmission resulting in congenital (in utero)infection. This is typically very severe. The fetal manifestations include microcephaly, hepatosplenomegaly, IUGR, and IUFD

renal disease pregnancy management

1. Specifically for this patient, how will you follow her in the first trimester? (5 points - any from below) · Referral to MFM, Nephrölogy · Baseline evaluation o OGTT (since on prednisone) o Baseline serologies: TORCH o Baseline BP, Urine analysis & culture, 24 hr urine for protein, BUN, Cr, lytes, LFTs, CBC, coagulation profile o Immunosuppressant levels 2. Specifically for this patient, how will you manage her in the second and third trimesters? (5 points - any from below) · Repeat renal and urine labs monthly · Uterine artery Dopplers, · Serial fetal growth/ well-being/ UA Dopplers · Close antenatal follow-up (q2weeks) · Monthly immunsuppression doses until 32 weeks, then q2weeks, and weekly at 36 weeks until delivery · Monthly scan of the graft · Anti-CMV IgG/ IgM each trimester (if neg at begin of preg) · Toxo screen q3-months · Anesthesia consult · NICU consult

advice for obese people pre-op What testing ?

1. Weight loss 1 2. Sleep apnea (STOP-BANG Q'aire) 1 3. DM /Medicine or Endocrinology consult 1 4. Stop/reduce smoking (8 weeks before) 1 5. Anaesthesia consult (all, but esp neck circumference > 60 cm) 1 /5 6. Treat yeast panniculitis/folliculitis preop 1 bonus

RPL history

1. What are some pertinent questions you would ask her about her history: /10 Obstetrical history: Date of each pregnancy, how many weeks, TTC, us results before SA, intervention, same partner Gyn Hx: cycle interval, flow, (sx of polyps/fibroids - spotting, menorrhagia; sx of ashermans) PMHX - VTE, autoimmune, thyroid, galactorrea/headaches Symtpoms of thyroid ? (cold intolerance, constipation, weight hain/loss, ..... Diabetes symptoms Prolactin symptoms Meds: previous OCP use? (any VTE with this) - bonus Any previous investigations? FHX: RPL, VTE, genetic Meds: anything teratogenic Lifestyle: caffeine, smoking, alcohol, drugs, weight/BMI

PCOS history (irregular menses, + elevated testosterone)

1. What do you want to ask her on history? /10 Identifying data · Age, GTPAL Menstrual history/HPI · LMP, menarche · Regularity/irregularity - range of cycle length, longest without period · Menorrhagia - ER visits, transfusions, flooding, dizziness or palpitations · Molimina - breast tenderness, mood changes, bloating · Intermenstrual bleeding · Postcoital bleeding · Acne - when, duration, treatments · Excess hair growth o Sudden or gradual o Lip, chin, chest, nipples, below umbilicus, inner thighs, lip o Methods of control, frequency · Virilization o Voice change o Loss of hair - male pattern baldness o Breast atrophy, clitoromegaly · Endocrine symptoms o Heat or cold intolerance, weight change, skin or hair change, bowel movement change, tremor, fatigue o Headaches o Visual changes o Galactorrhea · Investigations to date Gynehx Pubertal development Sexually active - hoping to conceive? Trying to become pregnant? How long? Infertility STI's, paps Contraception - now and past PMedhx Obesity DM Thyroid HTN Hyperlipidemia Meds Allergies PSurghx Social Smoking, EtOH, drugs Job, relationship Exercise Family history Infertility Irregular menses Diabetes Hypertension Hyperlipidemia Hypothyroid

endometrial cancer pre-op imaging

1. What investigations does the patient require preoperatively? ¨ CBC, Cr, LFTs, Group and Screen ¨ Chest X ray or CT chest - cardiorespiratory status, exclude pulmonary metastases

contraindications to TOLAC

1. prior classical or T incision 2. Major uterine reconstruction (full thickness myomectomy, repair of mullerian anomaly, cornuel resection) 3. prior uterine rupture 4. non-vertex presentation (although external cephalic version is not contraindicated) 5. medical or obstetric complications which would otherwise preclude vaginal delivery 6. h/o more of 3 or more CS (can try with 2) 7. unavailability of staff to perform emergency CD (ob and anesthesia) 8 Patient declines

concerning signs of respiratory failure

1. severity? ● Labored breathing ● Tachycardia ● Pulsus paradoxus ● Prolonged expiration ● Use of accessory muscles ● Cyanosis ● Central cyanosis (sign of potentially fatal attack) ● Altered consciousness (sign of potentially fatal attack)

CAH

AR inherited enzymatic deficiency where there is impaired synthesis of cortisol, resulting in adrenal hyperplasa 21 hydroxylase is the classic, causes high testosterone/andro also causes salt wasitng virilization of a female infant

RPL incidence how often is a cause found for RPL ?

ASRM definition: RPL = ≥ 2 failed consecutive clinical pregnancies, confirmed on ultrasound (following conformation of gestational sac) or histopathology, with the same partner ESHRE definition: considers counting biochemical loss/ectopics as pregnancy loss as well Incidence = 5% cause found in 50%

contraindications to UAFE

Absolute · Pregnancy · Pelvic/GU infection · Malignancy of reproductive tract · Allergy to contrast · Impaired renal function · Severe vascular disease · Decreased immune status Relative · Submucosal or pedunculated fibroids · Previous internal iliac or uterine artery occlusion · Recent GnRH agonist use

contraindications to assisted vaginal delivery

Absolute •Non-vertex presentation, unless forceps are used for face presentation or the after-coming head in vaginal breech delivery. •Unengaged head, with more than one-fifth of the fetal head palpable abdominally above the pubic brim. •Incomplete cervical dilation. •Uncertainty of the fetal head position. •Suspected CPD. •Fetal coagulopathy, thrombocytopenia, or brittle skeletal dysplasia. •Inability to progress to timely Caesarean delivery should the AVB be unsuccessful. Relative •Vacuum delivery for fetal prematurity, particularly <34+0 weeks gestation.

contraindications to assisted vaginal birth

Absolute •Non-vertex presentation, unless forceps are used for face presentation or the after-coming head in vaginal breech delivery. •Unengaged head, with more than one-fifth of the fetal head palpable abdominally above the pubic brim. •Incomplete cervical dilation. •Uncertainty of the fetal head position. •Suspected CPD. •Fetal coagulopathy, thrombocytopenia, or brittle skeletal dysplasia. •Inability to progress to timely Caesarean delivery should the AVB be unsuccessful. Relative •Vacuum delivery for fetal prematurity, particularly <34+0 weeks gestation.

absolute contraindications to methotrexate

Absolute contraindications include the following: - clinically significant renal or liver disease - blood dyscrasias - bone marrow suppression - pulmonary fibrosis - peptic ulcer disease - immunosuppression - chronic infections - concurrent IUP - breastfeeding. - Blood dyscrasias (anything that affects RBC, WBC, platelets.... clotting disorders, bone marrow)

) If you placed a lateral accessory trochar below the anterior superior iliac spine, what nerve are you at risk of injuring? (1)

Accept either ilioinguinal or iliohypograstic

immediate vs delayed ureteric repair

Actual cut-off day is controversial, 48 hrs to 5 days post-op, after that tissues are friable, inflamed and difficult to work with If < day 5 post-op, call urology and go back to OR If > day 5 - call urology, if unable to place stent in from below (retrograde) will call interventional radiology - percutaneous nephrostomy tube to be placed and urology will follow-up and take back to OR 6-8 weeks later (delayed repair)

PPH meds after vaginal delivery and CS

10mu IM with anterior shoulder (if term) OR 20-40 mU in 1L saline at 150cc/hr 5 mU IV can be given after SVD, but not CS oxytocin at CS can cause hypotension and myocardial ischemia

general management of OASIS

Administer antibiotics Good lighting Good exposure/assistance Adequate analgesia 3rd- overlapping or end to end repair Post delivery - consider foley - stool softeners - pelvic phyio - OB follow up

inpatient management of OHSS

Admit patient Daily weights same pain management, anti-emetics oral/IV fluids (IV saline, IV albumin) monitor ins/outs !! foley, or monitor urine output and specific gravity (assess hydration) anticoagulation (prophylactic doses of enox 40 sc daily or heparin 5000, based on weight) paracentesis (?indwelling cath preferable as long as > 50/day) culdocentesis /pleuracentesis

age of consent in canada

16 is in general Exceptions: - 18 if it involves "exploition" like pornogaphy or position of trust 12-13- 2 years older 14-15- up to 5 years older

contraceptive counselling history

2 -HPI -what is she currently using for contraception? -what has she used in the past? (including side effects) -when/if does she plan to have children? -how important to her is it not to get pregnant right now? /3 -PMHx -migraines -HTN -VTE -heart disease -liver disease -breast cancer -SLE /1 -PSxHx /1 -Meds /1 -Allergies /2 -Gyn -menstrual history -STI's -Pap -Gardasil /1 -OB Hx -GTPAL /2 -FHx -VTE, thrombophilia -gyn malignancy /1 -Social -smoking -EtOH -drugs -work, home situation

define recurrent UTI

2 in 6 months 3 or more in a year

primary amenorrhea history

2. What do you want to ask this girl on history? (Rapid Fire) Lifestyle Weight loss or gain Excessive exercise Diet extreme/trying to diet (eating disorder) Endocrine symptoms (hyperthyroid, diabetes, androgen excess, menopause, prolactin) Acne, excess hair growth Heat/cold intolerance, constipation/bowel changes, weight gain, fatigue, depression, hair, nail or skin changes Vasomotor symptoms CNS symptoms Headache, visual changes Galactorrhea Trauma Sexual/social history (with mother outside) Sexually active? Unprotected? Contraception, STI's Smoking, recreational drugs, alcohol Friends, school performance, activities, sports Menstrual history Age of menarche Irregular/regular menses Dysmenorrhea? Flow? Duration of menses PMedhx Chronic illnesses - malabsorption, renal, diabetes Malignancies - when, chemo or radiation or surgery Medication Allergies PSurg hx CNS, abdo/pelvis Family hx PCOS Chromosomal abnormalities POF, Fragile X do not foret HEADSS

chest pain physical exam

2. What would you like to do on physical exam? a. General appearance (cyanosis, toxic, coloration, pale, extremity cool, diaphoresis) b. Vitals sign : BP, H.R , 02 sat, temp, RR , BMI c. Neuro : oriented x 3 d. HEENT : stridor, jugular venous distension e. Respiratory : Air entry, rales/crepitus, wheeze - r/o pleural effusion, use of accessory muscles, pulmonary edema f. Heart : murmur, S3/S4 ,pericardial rub g. Abdomen: mass, ascites , hemoperitoneum/ascites. Surgical scar h. Legs : Homan's sign, erythema, edema , tenderness

anal incontinence after oASIS percent

20-40%

ITP threshold for delivery

25 vaginal 50- cesarean 75- epidural

hemabate dosing and sides

250 mcg q 15 mins, 8 doses These include, in descending order of frequency - diarrhea - hypertension - vomiting - fever flushing and tachycardia. Another pharmacological effect is bronchospasm...... Thus, carboprost should not be used for asthmatic women and those with suspected amnionic fluid embolism

monitor diabetic ultrasound and surveillence

28 weeks- ultrasound then q4 weeks ultrasound If Poorly controlled, may begin weekly surveillance at 32 weeks. Might not need it in well controlled. SOGC says weekly surveillence at 36 weeks (NST, BPP) If obesity, poor gycemic control, LGA, HTN, or SGA... can test earlier and more frequently than 36weeks.

OASIS sutures

3-0 PDS (preferred) 2-0 vicryl

Ling asymptomatic endometrial thickening

4 reasons to biopsy patients 1) vascularity 2) inhomogeneity 4) endometrial thickeness > 11 Tamoxifen 5 issues 1) polyps 2) hyperplasia 3) carcinoma 4) sarcoma 5) benign thickening Tamofixen lining increases 1mm year per use. it then regesses 1mm upon stopping it per year. if you do a biopsy and insufficient tissue - could be due to polyp AND atrophic lining - do an SIS- which would re-measure ET Higher risks - size > 2cm - older patients (age > 60 ) - risk factors (BMI, diabetes. etc)

what is the test of choice for HIV?

4th gen HIV-1 and HIV-2 Ag/Ab combo immunoassay is initial screening if negative, no infection If positive, needs a confirmatory test 2. To confirm, do multispot test (for HIV-1 and HIV-2 antibody differentiation if multispot detects HIV antibodies, HIV is confirmed 3. If multispot test is negative, do a HIV-1 Nucleic acid test (NAT) for RNA viral load Old way Screening test - ELISA - enzyme-linked immunosorbent assay to look for antibodies to HIV-1/HIV-2 and/or p24 antigen ..................................___/ 2 If test is positive, do a confirmatory test - Western Blot

lynch syndrome risk of endo CA

50% diagnosed at a younger age.

SOGC GDM testing

50g glucose -Normal = < 7.8 -Indeterminate = 7.8-11 -GDM = >11.1 2. 75g Fasting > 5.3 1 hour - 10.6 2 hour- 9.0 ANY of these count for GDM

TOLAC success what increased tolac failure ?

70-80% of women with CS will have a repeat CS about 70% successful less if for dystocia (higher if breech, or maternal reason) More likely for - tall women - previous SVD - normal size baby - spontaneous labor (as opposted to IOL) Less likely if they need -cervical ripening -augmentation -post dates - macrosomia (>4kg) - maternal obesity - maternal AMA

30F G2P1 at 33 weeks comes in with new onset of dyspareunia & severe vulvar pain. She had a fever & wasn't feeling well a couple of weeks ago. Take a history

: ● Age ● GPTLA ● Ethnicity ● Occupation HPI: ● When did the pain start, location, severity, alleviating/ aggravating factors ● Any vesicular lesions/rash? location, size, number? ● Dyspareunia: superficial/deep ● Any recent travel, sick contacts? ● Any STIs? ● Prodromal symptoms: malaise, fever, myalgia ● Local symptoms: dysuria, pain, soreness ● Previous attacks of genital/oral herpes ● Is the patient on immunosuppressants/immunocompromised? Known lupus, etc. ● Did the partner have herpes? Does he currently have any visible lesions? ● When did the fever start, did she measure it at home, any symptoms of infection e.g. UTI, URTI Antenatal hx: ● Planned pregnancy ● LMP, estimated GA (menses regular lately, dating US) ● MSS ● Symptoms: n/v, H/A, fatigue, abdo pain, PVB, cramps PMH: thyroid dz, DM, RA, DVT/PE, CT disease, Crohn's/UC PSH POBH: pregnancies, SAB/TAB, complications Meds Allergies Habits: smoking, ETOH, drugs FxHx: consanguinity

what does the guideline cite on home birth

A meta-analysis of these 4 studies comparing outcomes for women planning homebirth with those planning hospital birth found a - significant increase in spontaneous vaginal birth - significant reduction in interventions and maternal morbidity, including -induced and augmented labour - pharmacologic pain relief - obstetric anal sphincter injury - episiotomy - instrumented birth - Caesarean birth - infection Although postpartum hemorrhage occurred less often in those planning homebirth across studies, blood loss was measured differently, so the data were not pooled.

Rubella vaccination

A single dose of this vaccine will result in measurable antibody in almost 95% of susceptible persons; primary failure of the rubella vaccine occurs in less than 5% of immunizations. Antibody levels can be detected for at least 18 years in more than 90% of the vaccine recipients; however, up to 20% of vaccinated individuals will have rubella titres below the protective level after 2 decades from immunization

sexual assault history

A) Personal history GTPAL status /1 LMP /1 Cycle length and number of days of flow /1 Use of contraception /1 History of past STI /1 ?current antibiotics for a pre-existing pelvic infection /1 PMH /1 PSH /1 Allergies /1 Medications /1 Social history • smoking /1 • alcohol use /1 • drug use /1 ?lives alone/ in shelter/ married (etc) /1 ? Immunizations updated: Hep B, Tetanus /1 B) Assault History Location /1 Date /1 Time /1 Assailants (their number & sex) /1 Explain situation in which assault occurred: weapon threatening, private home, group party/bar, etc. /1 Any foreign objects inserted in orifices? /1 Any relationship of assailant to the victim? /1 Was condom used? /1 Was there penetration? • Vaginal /1 • Anal /1 • Oral /1 Any ejaculation? /1 Was there cunnilingus? /1 Was the victim injured in any fashion (bites, kicks, scratches?) /1 Last previous consensual intercourse? /1 Did the victim take a bath, shower, or douche since the assault? /1 Did the victim urinate or defecate since the assault? /1 Did the victim change her clothes since the assault? /1 Was the victim intoxicated by drugs or alcohol at time of assault? /1

PPH general management

ABC , 2 large boer IV vitals Take blood - CBC, PT/INR, crossmatch, liver/kidney function, lytes Call for help (anesthesia, senior OB, possibly heme) - alert blood bank Check for causes - besides atony, rule out tissue (RPOC), check for lacerations (cervical vs vaginal) , coagulopathy Empty bladder - foley uterine massage Give uterotonics, TXA Give fluids - if continued bleeding, give PRBCs +/- FFP, cryo, platelets, recombinant activated factor VII - if stable, consider - call radiology for embolization - Bakri balloon/Smith-Blakemore catheter - uterine packing - if not stable, move to OR - laparotomy - hypogastric/uterine/ovarian vessel ligation - uterine compression suture (B-Lynch), cho suture - stepwise devascularization - hysterectomy

OB trauma exam

ABC's Vitals, neurovitals O2sat & give O2 Start 2 large bore IV's (replace blood loss 3:1 with crystalloid) Foley catheter NG if any change in LOC or if intubation is required Continuous EFM toco for CTX Patient in LLD or wedge spinal board (if uterus is at or above the umbilicus) Assess for other injuries FULL body survey Abdo exam: tenderness, ctx, SFH, peritoneal signs, bruising, fetal presentation Pelvic: fluid, bleeding, Cx dilatation, any injuries Skeletal injuries - CBC - ABO coags - life function, kidney function, Give Rhogam if indicated Urinalysis U/S: free fluid (FAST scan), BPP, presentation, abruption Consults: • Anesth • GenSurg • Alert Peds in case need delivery Consider CT scan - cardiology (deceleration injury)

blood type and hydrops

ABO alloimmune HDN can occur with the first pregnancy. Although ABO incompatibility occurs in about 15 percent of all pregnancies, it results in neonatal hemolytic disease in only 4 percent of such pregnancies (ie, 0.6 percent of all pregnancies). ABO HDN is restricted almost exclusively to group A and B infants of group O mothers. It may be particularly pronounced in group B African-American newborns in whom the B antigen is more developed at birth than in the general population. Generally, a blood group O mother produces IgG anti-A or anti-B alloantibodies that cross the placenta and bind to her infant's type A or B erythrocytes and to other tissues that contain blood group A or B. On the other hand, in women with blood groups A or B, anti-A or anti-B alloantibodies (also called isohemagglutinins) generally are of the IgM class and do not cross the placenta.

What are the contraindications to using the Copper IUD?

ABSOLUTE -Pregnancy -Copper allergy -Unexplained vaginal bleeding -Severely distorted cavity -Immediately post septic abortion -Puerperal sepsis -Malignant trophoblastic disease

contraindications to TVT

ABSOLUTE CONTRAINDICATIONS Important structure potentially in the path of the trocars or sling □ Pelvic kidney □ Vascular graft Low ventral hernia Pregnancy Active oral anticoagulation RELATIVE CONTRAINDICATION Risk for significant adhesions to pubic bone e.g. ruptured appendix with peritonitis or stage 4 endometriosis

risks of cancers in lynch syndrome (hnpcc)

AD inheritance Colon- around 80% Endometrial- around 50% Ovarian- around 10%

ling atypical glandular ocse prepb

AGC: different than atypical squamous. Squamous- on cervix and vagina Glandular- on cervix, endometrium, fallopian tubes . Think about beyond cervix. Glandular abnormalities of cervix- benign (polyp) , premalignant (Adinocarcinoma in situ), malignant (adenocarcinoma) Endometrium - polyp, hyperplasia, atypia/malignancy. Things that change how cells look- IUD, COCP, progestins, Tubal- fallopian tube Evalneed to do pap, ECC, colposcopy (must look on exocervix, a squamous lesion and a glandular lesion could co-exist and often does 50% of the time.... Biopsy lesion if you see it). endometrial biopsy Ultrasound (check adnexa, rule out tupe) HPV typing- if positive, points to cervix more so. If endometrial hyperplasia or thickening, must do hysteroscopy to look. Possible polypectomy/D&C If high risk HPV positive- would do a cone. If you have to do cone and hysteroscopy Do the cone first- it may affect the microscopic reading Then ECC Then hysteroscopy Cone- benign atypia Endometrial hyperplasia can give glandular cells Cervical benign atypia- can be normal Any cone follow up post cone/leep - pap, ecc, colo q 6 months is UNIVERSAL - at 12 month mark, do an exit HPV - If HPV is positive, do annual typing. Mean clearing time of HPV is 9 months (this is why you do typing at 12 month mark, not at q6 because that is too soon). Benign hyperplasia of endometrium follow up - Medical: Mirena is great idea OR surgical (could do a hyst, depending on risk factors) - repeat biopsy in 3 months .... it should resolve in 1 year. - should ideally see 2 negatives - Medical options - MPA (high dose vs low dose) - Megace (high vs low dose) Patient who has cleared hyperplasia with progestin, after 1 year mark: - it may be reasonable to continue progestin since they have risk factors. - biopsies are not needed to be continued... unless they re-bleed.

BRCA breast and ovarian cancer risk

BRCA 1- 70 breast, 40 ovary BRCA 2- 60 breast- 20 ovary

when to perform BSO and mastectomy in BRCA ?

BRCA1- 35 to 40 BRCA2- 40 to 50 ---Ovarian cancer risk decr by 80-96% --Ovarian cancer mortality decr by 80% --Breast cancer risk decr by 50% --Breast cancer mortality decr by 50%

Non surgical, non medical PPH management

Balloon tamponade Uterine packing Uterine artery embolization

Molar D&C hemorrhage

Balloon tamponade and angioembolization have been described for uterine preservation in cases of severe hemorrhage post-evacuation. other uterotonics (ergomet, hemabate, TXA) Oxytocin after 14 weeks Don't forget to give winRHO for ALL patient Rh neg within 72 hours (required for partial, but final dx requires path, and may miss partial)

treat DKA in pregnangy

Baseline labs- and keep checking hourly (serum glucose, anion gap, bicarb, pH, electrolyes) 1) Step 1 is fluid bolus- normal saline 2) Regular infusion of insulin 3) critical to maintain potassium at 4-5 (remember, even with a normal serum potassium, their total body potassium is VERY low) - hold briefly if > 5.5 - if level is normal, give infusion of 40 meq per hour 4) Once glucose is less than 250 (14), add 10% dextrose to the existing saline at 125 ml/hr... until DKA is resolved 5) Consider 1 amp of bicarb if pH < 7.1 6) Always treat the cause Metabolic targets (CHECK per hour): -reduce ketones by ~0.5 mmol/L - decrease capillary glucose by 3 mmol/L (54 mg/dL) - VGB or ABG increase HCO3- by 3 mmol/L (3 mEq/L) - electrolytes Resolution pH > 7.3 anion gap < 12 bicarb > 15 blood ketones < 0.6 mmol/L

baseline screening obesity

Baseline screening where indicated could include renal function (with screening for proteinuria and serum creati-nine levels), liver function tests, cholesterol, triglycerides, thyroid stimulating hormone, diabetes screen, electrocar-diogram, pulmonary function tests if there are any respi-ratory concerns OSA

determine chorionicity

Best performed early (before 10 weeks) 1. Number of gestational sacs Note: before 6 weeks, possible that 1 gestational sac can still be dichorionic 2 gestational sacs = 2 chorions .... etc 2) A thick band of chorion that separates two gestational sacs signals a dichorionic pregnancy, whereas mono- chorionic twins have a single gestational sac. (this is because), monochorionic pregnancies have a dividing membrane that is so thin (generally <2 mm) that it may not be seen until the second trimester. Early in double digit weeks at 10 to 14 weeks' gestation, sonographic assessment of :chorionicity may be determined using 4 factors: 1) Gender (if different, it's obviously dichorionic... if same, it could be either monochorionic or dichorionic) 2) number of placentas (careful, could be 2 fused... AKA bipartite) 3) presence of an intervening membrane dividing the sacs (lambda sign vs t-sign) 4) thickness of the sacs (and number of layers) Dichorionic- 4 layers (amnion-chorion-chorion-amnion) Thicker- >2 mm =dichorionic PPV ~ 95% Monochorionic - 2 layers- (amnion-amnion) Thinner- ≤2 mm =mono PPV ~90%

cmv testing fetus

Best to do an amnio for CMV DNA PCR (not a viral culture) , should be 6-8 weeks after infection Of note, quantifiable CMV PCR can be done and IS predictive of outcomes

risks and benefits of genetic testing

Better adherence to monitoring guidelines Preparing for the likelihood of becoming ill in the future Reduced uncertainty Importance of counseling by a genetics professional a. Risks: jeopardize insurance coverage, psychological impact of knowledge, possible impact on family dynamics, concerns re confidentiality b. Benefits: possible decrease in morbidity and mortality, decreased anxiety if found to be on-carrier, possible prevention of unnecessary surgery

what to have ready for PAS delivery

Blood products (RBC, platelets, FFP) - cell saver Anesthesia - consider GA (but regional anesthesia preferred) - art line

COC and breast and cervical cancer

Breast cancer: taking the combined pill slightly increases the risk of breast cancer compared to people who do not take it. Ten years after stopping the pill, a person's risk is no longer increased - as if the pill was never used. Cervical cancer: may be a slight increase correlation doesn't mean causation

milestones history

Breast development Pubic hair Growth spurt menstruation

tumor markers

CA 125 LDH (dysgerminoma) AFP- yolk sac Granulosa- inhibin A, B , estrogen CEA: GI High Ca125/CEA ration (>25) suggests primary ovary, if <25 suggests metastatic to ovary from colon -CA 19-9 elevated in GI adenocarcinomas esp pancreas - CA15-3 - breast -consider CT pelvis, chest abdomen if metastatic disease suspected

hyperemesis labs

CBC lytes, ext lytes BUN Creat LFT's BhCG TSH , +/- free T4/T3 Urinalysis for ketones Ultrasound

what evals for someone doing donor sperm ?

CBC possibly an electrophoresis Infectious serology (HIV, Hep B,C, Rubella, CMV, syphillis, varicella) CMV is important for donor sperm Normal infertility workup Day 3 bloods LH, FSH, prolactin, TSH, E2 AFC, AMH Tubal: HSG, hycosi Uterine: SIS, regular ultrasound.

when to do more extensive imaging for post molar ?

CT chest/abdo/pelvis MRI brain MRI pelvis Do these if : - lung mets on CXR >2cm - GTN after a non molar pregnancy (!!) - histologic Dx of choriocarcinoma - Histologic Dx of PSTT or ETT) - Recurrent GTN An arterial-phase CT scan of the abdomen is required in order to accurately identify liver metastases.

counseling on pprom, when to come in

CTX, PVB, decreased FM Vaginal discharge fever, n/v, unwell tachycardia

stillbirth workup

CVS or amnio before delivery - the cell culture analysis failure is high in stillbirth, around 50%. so it would be better to do CVS or amnio on the fetus ..... do for karyotype/microarray, plus TORCH/infections screening. consider maternal serologies Most important are: - placenta histology - Kleihauer detailed history ● Bloodwork ○ Hypertensive disorders: CBC, LFTs, urate ○ Abruption: Kleihauer ○ Diabetes: Random glucose, HbA1c ○ Immune hydrops: T&S ○ Infection: Toxo, rubella, CMV, Herpes, Hep A, Hep B, VDRL, HIV, Parvovirus B19 ○ Coagulopathy: INR, PTT, fibrinogen ○ Thrombophilia: FVL, prothrombin, antithrombin, protein C, protein S, lupus anticoagulant, anti-cardiolipin, homocysteine ○ Autoimmune: ANA

bladder injury repair

Call for help - urology Carefully identity the site of injury Close in 2 layers with 3-0 abdorbable suture check the ureters Cysto to ensure ureters/tight seal Foley for 7-10 days

Rubella findings on ultrasound

Cardiac defects Ophthalmic defects Microcephaly Hepatosplenomegaly Fetal hydrops Bowel hyperechogenicity Intrauterine growth retardation (IUGR)

what are indications for PGD? When can you do sex selection?

Carriers of single gene (AR, AD, X-linked ) Carriers of structural chromosomal abnormalities (balanced reciprocal/robertsonian) to prevent inheritance of x-linked disorders

treat PID inpatient

Ceftriaxone 1 g IV every 24 hours PLUS Doxycycline 100 mg orally or IV every 12 hours PLUS Metronidazole 500 mg orally or IV every 12 hours OR: Clinda 900mg + gent 5mg/kg (max 400mg) OR Cefoxiten 2g IV q6h + Doxycycline 100mg PO/IV q12h Treat afebrile for at least 24-48 hours then step down, 14 days total (doxy + flagyl)

neurologic outcomes of preterm birth

Clinically important adverse neurological outcomes associated with preterm birth include CP and motor impairment. Other adverse outcomes include: - blindness - deafness - developmental delay, - cognitive delays - poor academic performance - behavioural disorders

treat high risk & ultra high risk GTN

Combo chemo Weekly hCG monitoring should be continued until normalization of serum hCG. consolidate treatment with 3 cycles (6 weeks) of chemotherapy after normalization of hCG. Ultra High-risk patients with liver and brain metastases or those with a modified WHO score as adapted by FIGO of >12 are considered ultra high risk. These patients may die during treatment as a result of acute hemorrhage or complications from extensive disease. Low-dose induction chemotherapy with etoposide and cisplatin for 1 to 3 weeks, followed by EMA-EP or EMA-CO chemotherapy, has been shown to reduce early death in ultrahigh-risk patients Consolidation chemotherapy after normalization of serum hCG continues for 4 cycles (8 weeks). Although no randomized data exist to compare regimens in ultrahigh-risk patients, those with liver and brain metastases may benefit from EMA-EP as a first-line, multi-agent treatment after induction chemotherapy The potential for cure in high-risk patients is 70% to 95%. Previously, those with ultrahigh-risk disease were at risk of early death, with a survival rate of only 25% to 50%. If treated with induction chemotherapy, these ultrahigh-risk patients now have a prognosis similar to those with high-risk disease. BEP is an option

cmv infant complications

Complications of affected infants with congenital CMV infection include - jaundice - petechiae ("blueberry muffin baby") -thrombocytopenia - hepatosplenomegaly, as well as late complications, such as - sensorineural hearing loss - mental retardation - delay in psychomotor development - visual impairment - chorioretinitis, - optic atrophy - seizures - expressive language delays, and learning disabilities

surgical management of PPH

Compression sutures (B-Lynch, vertical, Cho square) Artery ligation (uterine, hypogastric) Hysterectomy

maternal HSV testing

Confirm diagnosis by laboratory testing - Swab performed on mucocutaneous lesion either 2 ways 1. PCR = more sensitive, results in 1-2 days 2. Viral culture = low sensitivity as vesicular lesions ulcerate/crust, results 7-14 days..... "A negative test in the presence of active lesions does not rule out HSV because viral shedding is intermittent" -3. Serology testing - "If there are no active lesions but exposure to HSV is suspected, serologic testing may be used. IgG to HSV1/2 (AKA, non specific HSV IgG) develops before type-specific IgG to HSV-1 and HSV-2 glycoproteins, which take an average of 2-3 weeks and up to 6 months to develop. If the suspected exposure was particularly recent, nonspecific IgG to HSV-1/2 should be tested first, with reflex to the type-specific antibodies. If the exposure was in the past, type-specific testing for IgG to HSV-1 and HSV-2 glycoproteins alone can be performed. Note: RCOG advises that "For women presenting with first episode genital herpes in the third trimester, particularly within 6 weeks of expected delivery, type specific HSV antibody testing (immunoglobulin G [IgG] antibodies to HSV-1 and HSV-2) is advisable. For these women, characterising the infection will influence the advice given regarding mode of delivery and risk of neonatal herpes infection. The presence of antibodies of the same type as the HSV isolated from genital swabs would confirm this episode to be a recurrence rather than a primary infection and elective caesarean section would not be indicated to prevent neonatal transmission....... However, it should be noted that it may take 2-3 weeks for the results of this test to become available. It is therefore recommended that an initial plan of delivery should be based on the assumption that all first episode lesions are primary genital herpes. This plan can then be modified if HSV antibody test results subsequently confirm a recurrent, rather than primary, infection.

breech management

Confirm presentation with ultrasound - determine the size, kind of breech, neck flexion Oxytocin is allowed Continuous EFM Good continual progression Adeqate analgesia Skilled attendant abolity to perform a CS forceps

manage lynch syndrome

Consider to screen with YEARLY endometrial biopsy age 30 (or 5-10 years before age where a family member was diagnosed with cancer) RR Hyst once completed family Consider BSO (remember risk of 10%)

1. How would you manage this patient in labour?

Continue with regular doses of methadone or buprenorphine during labour (need to get special emergency license through health Canada if patient doesn't bring her own supply "carries") .............................. ___/2 Ensure patient received adequate pain relief - May require higher or more frequent doses because of tolerance ....................................... ___/2 If not on methadone and presenting in labour, treat with morphine if presenting with withdrawal symptoms ...........................................

contraindications to IOL

Contraindications - any contraindication to labor o Placenta previa o Vasa previa o Malpresentation (??) o Prior classical or T incision on uterus o full thickness myomectomy o Active genital herpes o cephalic pelvic disproportion o Invasive cervical carcinoma o Previous uterine rupture

rubella vaccine contrindications .... and when to delay post partum? when to get pregnant after it ?

Contraindications to rubella vaccinations include - febrile illness - certain immunodeficiencies - systemic immunosuppression - history of an anaphylactic reaction to neomycin, - pregnancy. Other reasons to delay post partum = - delay for 1 month if any immunoglobulin-containing preparations, including Rh immune globulin, IVIG, or blood products, during pregnancy or the peripartum period, as vaccine effectiveness may be reduced. - Rubella vaccine virus has the potential to cross the placenta and infect the fetus..... However, there has been no report of CRS in the offspring of women inadvertently vaccinated during early pregnancy..... Therefore, pregnancy termination is not recommended for these patients. Given the potential risks to the fetus, women are advised not to become pregnant for a period of 28 days after immunization.

fetal blood sampling criteria and contraindications

Criteria to consider FSBS include: Cephalic presentation Gestational age >34 weeks gestation Delivery is not imminent Facilities and expertise exist to perform the analysis in a timely manner Membranes are ruptured, and cervix is at least 2−3 cm dilated Consent was obtained to perform the procedure Facilities exist to respond to an abnormal result Contraindications to FSBS include: Face/brow or unknown presentation Known or suspected fetal bleeding disorder (hemophilia, thrombocytopenia) Family history of a bleeding disorder (hemophilia, von Willebrand) Active maternal infection (HIV, genital herpes, hep B/C, known or suspected intrauterine sepsis)

which twin is which ?

Labeling each twin — It is important to use a consistent strategy for identifying and labeling each twin over serial examinations in the second and third trimesters. The majority (80%-90%) of twins are laterally (right/left) oriented, rather than vertically (top/bottom) oriented SOGC: In laterally oriented twins, the twin on the maternal right should be assigned the label twin A. In vertically oriented twins, the inferior twin should be assigned the label twin A. Twins should be assigned labels at the first sonographic scan, and labelling should be maintained for all subsequent scans. During the scan, the location of the twins (right/left, anterior/posterior, superior/inferior) should be documented, as well as other discriminating features that can help with the accuracy of labelling, including relative fetal biometry, structural anomalies or variants, sex, location of the inter-twin membrane, placental location, and placental cord insertion. 22 Documentation of the sites of placental implantation (anterior, posterior, lateral) and of the sites and types of placental cord insertion (eg, marginal versus central, normal versus velamentous) is also useful. Twins may not deliver in the order expected from antenatal ultrasound (termed perinatal switch), especially when delivered by cesarean.

molar workup vs post molar GTN workup

Laboratory investigations include : complete blood count, ABO - electrolytes - PT/INR (surgery) - creatinine liver enzymes thyroid-stimulating hormone quantitative total hCG, and urine protein. Imaging for patients with molar pregnancy typically includes only a pelvic ultrasound scan post-molar GTN requires - a chest X-ray to look for lung metastases - a pelvic ultrasound scan to assess extent of disease in the pelvis . On chest X-ray, lesions ≥6 mm would be expected to be visible. If the chest X-ray findings are negative, no further imaging is required. The likelihood of clinically significant metastases is negligible in the absence of lung or vaginal metastases. coriocarcinoma or GTN after a non-molar pregnancy: a more extensive workup is recommended because the incidence of metastases can be greater than 40%. - Pelvic ultrasound - CT scan of the chest and abdomen (with arterial phase through the liver) - MRI of the brain.

Latent syphilis

Latent Syphilis [6,8-10] • In latent syphilis, by definition, the patient is completely asymptomatic active disease although disease remains detectable by positive specific treponemal serologic tests [FTA-ABS (fluorescent treponemal antibody absorption) Latent syphilis is further subdivided into stages based on the duration of infection: early latent, late latent, and latent of unknown duration. Early Latent Syphilis • Early latency is defined as the time period within one year of initial infection. • 90% of relapse occurs during this time period; mucocutaneous lesions are most common. Patient is infectious when lesions are present. • Patients are believed to be potentially infectious in the absence of lesions. • Vertical transmission of infection may occur. Late Latent Syphilis • Initial infection has occurred greater than one year previously. • Associated with host resistance to reinfection. • Sexual transmission is unlikely. • Transplacental infection of the fetus can occur but is less likely than with earlier stages of disease. • Infection via blood transfusion is possible. Latent Syphilis of Unknown Duration • Date of initial infection cannot be established as having occurred within the previous year and patient is aged 13 to 35 years and has a nontreponemal titer ≥1:32.

manage menopausal hot flashes

Lifestyle modifications including reducing core-body temperature, regular exercise, weight management, smoking cessation, controlled breathing may be recommended to reduce mild vasomotor symptoms. IC Avoid trigers (smoking, drinking) non-pharmacologic SSRI - Sertraline/paroxitine SNRI - Venlafazine Clonidine Pregab/Gabapentin

lifestyle management of SUI

Lifestyle modifications: □ Smoking cessation □ Decrease caffeine and carbonated beverages intake □ Weight loss □ Exercise □ Timed voiding Pelvic floor retraining: □ Kegel exercises - written or verbal instruction (+/- digital feedback, +/- physiotherapy) □ Biofeedback - includes vaginal cones Incontinence Pessary: □ Ring or dish with knob □ Uresta Follow-up in 3 to 6 months

options to treat GUSM besides extrogen

Lubricants moisturizers SERM (ospemifene) DHEAS Vaginal laser

unexplained infertility workup

D3 FSH, LH, E2, PRL, TSH, hCG - Transvaginal ultrasound for AFC, uterus, ovaries Ovarian reserve : AFC, AMH, - Tubal patency testing: HSG, HyCoSy - Luteal progesterone - Semen analysis

treat ITP in pregnancy

Daily prednisone consider stronger steroid- methylprednisolone IV-IG if that fails Treatment Therapy is considered if the platelet count is below 30,000 to 50,000/μL Differences between glucocorticoids and IVIG include: IVIG works more rapidly (range, 1 to 3 days) than glucocorticoids (range, 2 to 14 days) Efficacy (both short term and long term) is similar, as discussed below. Glucocorticoids are generally easier to administer. Glucocorticoids are less expensive. For critical bleeding, a glucocorticoid and IVIG are given together Consider platelets if severe bleeding Splenectomy- last resort

manage mild/moderate OHSS

Daily weights, abdo circumference treat abdo pain - tylenol. opioids if needed -Non-steroidal anti-inflammatory agents with antiplatelet properties should not be used because they may interfere with implantation and may also compromise renal function in women with severe OHSS anti-emetics AVOID strenuous exercise because of enlarged ovaries and risk of cyst rupture or torsion (intercourse, high impact exercise) encourage hydration) outpatient paracentesis, or culdocentesis monitor body weight, abdo girth

describe UAFE Risks, benefits

Describe the procedure, risks and benefits Procedure · MRI to assess fibroid location/size and rule out adenomyosis · Baseline labs (CBC, INR, PTT, BhCG) , swabs and urine to rule out infection · Interventional radiology · Femoral line inserted and wire guided into internal iliac à uterine · Blood supply to fibroid identified using contrast · Embolization performed Risks · Failure of procedure · Incomplete embolization · Allergic reaction to contrast dye · Hematoma or infection at puncture site · Early/acute abdo pain Post embolization syndrome (40%) - pain, fever, leukocytosis, N/V · Post op infection (1%) · Misembolization of non target organ (i.e. bladder) · Ovarian/menstrual dysfunction · Transcervical myoma expulsion · Chronic pain · Need for hyst (1-2%) Benefits · 80-90% improvement of symptoms o Menorrhagia o Dysmenorrhea o Urinary frequency · Decrease in fibroid size o 33% by 3 months o 50-60% by 1 year · Amenorrhea 7-8% o 3% <40y, 41% >50y · Day procedures What are the long term complications of the procedure? · Ovarian dysfunction · Menstrual dysfunction · Chronic pain · Need for hyst If a pt became pregnant accidentally after UFE, what would you counsel about risks? Limited data... · SA - 15 - 30% · Abnormal placentation - accreta, increta, percreta · IUGR · PTD · C-section - 65% · Malpresentation

Von willebrand treatment HMB

Desmopressin Factor 8 replacement Platelets (type 3) Balloon tamponade Estrogen - IV or COCP TXA Progestin only Menstrual suppression options

Bishop score

Determines maternal readiness for labor by evaluating whether the cervix is favorable by rating cervical dilation effacement consistency position station Favorable , >6 or 8

preeclampsia vs lupus flare

Difficult to assess difference as many overlapping features ○ Thrombocytopenia ○ Hemolytic anemia ○ Proteinuria ○ Seizures • With lupus flare, expect to see ○ ↑anti -ds DNA titres ○ ↓ C3 and C4 (consumption) ○ Active urine sediment (casts)..... • May have normal BP with lupus flare

manage GT

Do not require any additional testing or specialized care, except follow-up platelet counts. Monitor for clinical evidence of other diagnosis: AITP / TTP / PET / HUS Follow platelets MFM, HEMATOLOGY, Anesthesia, NICU consults - if needed If platelets < 80,000 / uL, regional anesthesia unlikely do not give steroids or IVIG (wont work)

documentation in AVD

Documentation May Include but is Not Limited To: •Date/time •Physician(s) involved/present •Indication •Anaesthesia type •Record of discussion with the patient of the risks, benefits, and options •Position and station of the fetal head (abdominally and vaginally) •Amount of moulding and caput present •Assessment of maternal pelvis adequacy •Assessment of fetal heart rate and contractions •Type of vacuum or forceps used •Number of attempts and ease of application of vacuum or forceps •Duration of traction for forceps and duration of application for vacuum (start and stop time noted), along with an estimation of force used •Any rotation applied with forceps or autorotation that occurs with vacuum •For vacuum, number of pop-offs •Condition of newborn at delivery, with personnel present for potential resuscitation •Position of chignon on fetal scalp (vacuum): flexing versus deflexing; median versus paramedian application •Description of any maternal and neonatal injuries •Initiation of monitoring for subgaleal hemorrhage (vacuum)

diagnose post molar GTN diagnosis How to treat ?

During post-molar follow-up, persistent disease is diagnosed when any of the following criteria are met: •A rising serum hCG level, defined as a >10% increase compared with the previous level for 2 consecutive weeks (3 levels measured on days 1, 8, and 15) •A plateau in serum hCG levels, defined as a <10% change compared with the previous level for 3 consecutive weeks (4 levels measured on days 1, 8, 15, and 22) •A histologic diagnosis of choriocarcinoma (note: re-biopsy is not recommended) •Evidence of metastatic disease •A serum hCG level ≥20 000 mIU/mL more than 4 weeks post-evacuation In this case Refer to Gyne onc - chest X-ray - pelvic ultrasound scan, i Consider CT chest/abdo/pelvis (chest mets > 2cm !!!!) Consider MRI brain MRI pelvis

causes of incontinence after a post op pelvic procedure

Early □ Unsuccessful or unsustained surgical repair □ Latent SUI not recognized before prolapse surgery □ Surgical complication e.g. fistula □ Surgery was inappropriate therapy or inappropriate procedure used □ OAB (pre-existing or de-novo post-op) □ UTI □ Voiding dysfunction Late □ Deficient pelvic floor support (genetic, medical condition) □ Predisposing medical condition (COPD, obesity, constipation) □ Aging / estrogen deficiency

categories of OHSS

Early < (9 days from trigger) Late > 10 days after trigger Mild: bloating, pain, ovarian size>8cm Moderate: N/V, ascites, 8-12cm Severe: pleural effusion, oliguria, hypoproteinemia, hct >45%, ovarian size >12cm Critical: tense ascites, anuria, hct >55%, WBC>;25, VTE, ARDS initially just - mild abdominal pain - bloating - some nausea/vomiting... - often undetectable ascites, causing some mild weight gain when it gets worse, can have worsening of these.... - detectable ascites, with distended/tense abdo - dyspnea (pleural effusions) - dehydration symptoms (oliguria, hemoconcentraction) Severe progression includes ARDS VTE (hematoconcentration) hepato-renal failure

risks of CVS

Early amnio - limb defects ie. club foot (1.6%), SA (2.5%), early PPROM and its associated anomalies, higher failure rate of the procedure and cell culture Amnio T2/3 - SA (0.5-1%), PTL, PPROM/amniotic leaking (1%), chorio (<1%), RH isoimmunization if Rh-, Hep B/C/HIV transmission (avoid putting needle trhough the placenta) CVS - SA (1%), PPROM, chorio, Rh isoimmunization,

echogenic bowel causes

Echogenic bowel can be due to: ð Aneuploidy .................................................................................___/1 ð TORCH infection ............................................................................___/1 ð Swallowed blood ............................................................................___/1 ð Fetal cystic fibrosis..........................................................................___/1 ð Fetal bowel obstruction ....................................................................___/1 ð Echogenic bowel is commonly seen in growth restricted fetuses.......................................... ___/1

sexual assault follow up

Ensure she sees social worker, preferably before discharge Avoid intercourse before prophylaxis Abx completed Tell patient to expect bleeding within 21 days of emergency OC and redo pregnancy test if not F/U visit in 1-4 weeks (cultures, pregnancy etc) Hep B vaccine (if needed) dose 2 and 3 HIV tests in ~3months/6 months

what can IA assess How long to listen, and when?

FHR baseline, if regular or irregular, accels, decels cannot assess: variability, type of decels Listen: 30-60 secs after CTX

risk of forceps to mom

Failure needing CS, with tougher CS (impacted head) OASIS - with incontinence Vaginal/cervical laceration (ie, preterm birth) PPH Urinary retention Uro-gyne complications in life (prolapse)

risks of conservative management of PAS

Failure, depending on the study up to half may need an emergency hyst postpartum hemorrhage infection, sepsis, disseminated intravascular coagulation uterine arteriovenous malformation and choriocarcinoma

Ferriman-Gallwey score

Ferriman-Gallwey score upper lip, chin, - chest - upper back, lower back - upper abdomen, lower abdomen - upper arms - thighs >8 = excessive (95th percentile) Mild < 15 Mod 15-25 Severe > 25

fetal sides of thioamides

Fetal: ● Fetal hypothyroidism ● Fetal goiter ● Methimazole embryopathy o Choanal atresia o Esophageal atresia o Aplasia cutis

varicella in pregnancy exposure history

Full OB history - dating (very important) - symptoms of varicella - were they vaccinated? did they have it as a kid ?

when to treat for GBS What ABX ?

GBS unknown and preterm GBS unknonwn and 18 hours ROM previous infant with GBS disease GBS bacteriruia Positive GBS swab If a fever, treat as chorio Antibiotics: 1) Penicillin G, 5 million u IV bolus, then 2.5million q4h or, Ampicillin 2g IV x 1, then 1g IV q4h Allergy (low risk of anaphylaxis) 1) Ancef 2g IV x1 then 1g IV IV q 8 h Allergy (high risk anaphylaxis ) Clindamycin 900mg IV q8h (if susceptible) OR Vanco 1g IV q12h

risks of obesity pregnancy

GDM HTN PEC VTE IOL CS Stillbirth Macrosomia NICU Childhood obesity

Intrapartum diabetes management

GDM diet- patient can monitor sugars If on insulin: - insulin and glucose infusion with hourly sugars to allow for adjustment of insulin dose - EFM - ensure good progress · Prepared for shoulder dystocia · If EFW > 4500g, can consider offering elective c-section given high risk of shoulder dystocia (~40%)

Metformin risks

GI upset, diarrhea, nausea/vomiting impaired liver function Kidney function Rare- lactic acidosis

VTE DVT exam

General impression - ? Distressed ......................................................___/1 Vital signs - BP, RR, HR .................................................................___/1 Body habitus ................................................................................___/1 Abdo exam and assessment of pregnancy - SF height, Leopold's, Fetal heart ...___/1 Examination of both lower legs: Any visible redness .................................___/1 Edema - symmetric or asymmetric .....................................................___/1 Areas of heat or tenderness to palpation ................................................___/1 Measurement of calf circumference to confirm 10cm below tibial tuberosity ...___/1 Discrepancy .................................................................................___/1

conservative options for painful bladder

General relaxation / stress management Pain management ● Physical therapy ● Treat comorbid conditions (IBS, endometriosis, etc.) Patient education • Interstitial cystitis society website • Support groups Self-care / behavioural modification ● Diet modification: identify triggers and eliminate them o Spicy foods o Citrus fruits o Coffee/tea o Alcohol o Pineapple o Carbonated beverages o Tomatoes ● Exercising ● Timed voiding Over-the-counter products ● Pyridium (analgesic) ● Quercetin (bioflavonoid with anti-inflammatory properties) ● Calcium glycerophosphate (acid neutralizer)

syphilis exam

General: height, weight, BMI Vitals: BP HEENT: Eyes (?iritis) CVS: Heart (?murmur) Resp: Abdomen: SF height, FH, palpate for masses, HSM Pelvic: Ext/internal genitalia - condylomata, inguinal lymphadenopathy, look for evidence of other STIs, swabs again if not done previous visit, Pap Derm: Rash, distribution (palm/soles/trunk), gummatous lesions Neuro: General paresis, tabes dorsalis (weakness, loss of knee DTR's - Westphal's sign, Tabetic gait - loud noise as feet strike the ground from loss of proprioception...)

thyroid storm investigation and management

Generally, to progress to thyroid storm, you need a second insult (such as surgery, sepsis etc.). ABC's Check FH, continuous monitoring 2 LB IV's, O2 Urgent endocrinology/medicine consult Bloodwork - CBC, lytes, BUN, creatinine, AST, ALT, coags, fibrinogen, TSH, T4, T3, urine R+M and culture CXR, ECG, cardiac monitoring 1) 800 mg PTU (or NG) immediately .... then 200 q4-6 hours 2) give a iodide to suppress thyroid production - sodium iodide - potassium iodide - lugol's 3) symptoms with beta blockers (if not hypotensive or in heart failure) Propranolol 20-80 mg PO.... or 1mg IV q5 mins (up to 6mg) 4) consider dexamethasone (Corticosteroids inhibit peripheral conversion of T4 into T3)

primary prevention of OHSS

GnRH antagonist cycles as opposed to GnRH agonist cycles GnRH agonist trigger over hCG trigger Progesterone for LPS over hCG Low dose gonadotropins Low dose hCG trigger Cabergoline on hCG trigger Secondary Coasting- postponing hCG administration (3 days) until the patient's serum estradiol (E2) level decreases to a 'safer' level Freeze all cycles and subsequent ET, as opposed to continuing with fresh transfer..... (this is also probably better than coasting) cycle cancelation- OHSS will not develop in the absence of exposure to exogenous hCG or LH or to an endogenous LH surge as long as a pregnancy does not develop. Single transfer (eSET) as opposed to dual transfer

causes of dysmenorrhea or pelvic pain

Gyne causes - endometriosis, adenomyosis - ectopic pregnancy - degenerating fibroids - primary dysmenorrhea - PID , adhesions - Pelvic congestion syndrome - ovulation - torsion - ruptured cyst Other causes : - myofascial causes , nerve intrapment, muscle spasm - rheumatic causes - GI causes (Diverticulitis, IBS/IBD, appendicitis celiac ) - GU causes (kidney stones, UTI, pyelo, painful bladder) Psychologic- depression Remember to ask: OB history Sexual history Contraception LMP

cholestasis history

HISTORY Identifying Data ● Age ● Ethnicity Pregnancy history ● GPA ● LMP ● Antenatal history: regular follow-up, pregnancy complications (T1,2,3), ultrasounds, serology results (HIV, Hepatitis), previous immunizations ● Medications (? Antibiotics, over the counter medications/therapies) ● Allergies ● OBS history: Dates, GA, - complications, history of HTN, pre-eclampsia ● GYNE: PID / infections, cycle regularity ● Habits: Alcohol (if yes - ounces/week, CAGE), smoking, drugs ● Family history: genetic / chromosomal disorders, pre-eclampsia / HELLP, acute fatty liver or cholestasis, IUFD, children born ill / syndromes HPI ● Pruritis: Location, onset (acute/chronic), severity, progression on the body, intermittent/constant, course (progressing?) , exacerbating or alleviating factors ● Jaundice / skin discoloration? o Location, onset (acute/chronic) , progression, course (progressing), exacerbating or alleviating factors ● RASH? o Location, onset, progression, course (progressing) , exacerbating/alleviating factors o Description: macules, papules, raised, color, shape, ● Associated symptoms: fever, nausea, vomiting, SOB, Headache, visual disturbance, epigastric pain, malaise, ● Recent travel, sick contacts, change in diet ● Medical history: o Viral Hepatitis (type (ABCDE), dates, treatments o HTN, diabetes, hyperlipidemia o pre-eclampsia, HELLP syndrome o Autoimmune disease: thyroid? Ulcerative colitis, rheumatoid arthritis ● Surgical history: cholycystectomy, previous liver biopsy? ● Current fetal status: good fetal movements? Abdominal pain? Bleeding? Fluid leak?

Epilepsy history

HPI • Confirm GTPAL • When diagnosed with seizure disorder • Precipitating events? (trauma, drugs, infxn) • What type of seizures - partial, generalized • When last seizure was? • How often they occur? Is it improving ? • Current medications • Any recent changes to medications - Drug levels ? • Who following? POB/Gyn Hx • GTPAL - history of previous pregnancies • LMP - menstrual cycle • Pap smears - any abn • STIs • Current contraception - actively trying to become pregnant? PMHx/SxHx • Other medical conditions • Surgeries Meds/Allergies • Which anticonvulsants/doses/#meds • Using folic acid/PNV? SHx • Smoking/Etoh/drugs • Partner - hx of seizures FHx • Congenital anomalies - NTD • Genetic disorders • Chromosomal abn • HTN, DM, VTE

SLE history

HPI • When disease diagnosed • Presentation • Flares: Most recent flare, how often flares, most severe flare • What symptoms usually have • Any current symptoms • Any renal involvement (>50% pts) • Other organs involved? • Known antiphospholipid Abs • Anti SSA (Anti-Ro) or SSB +ve (Anti-La) • Current medications - doses stable? POB/GynHx • GTPAL • Outcomes of any previous pregnancies • Neonatal complications of previous pregnancies • Pregnancy complications suggestive of APAS ○ Recurrent SA ○ T2 or T3 IUFD ○ Severe pre-eclampsia or IUGR <34wks • Pap Hx • STIs • Current contraception PMHx & PSHx • VTE • Renal disease • Hypertension Meds & Allergies • Steroids, NSAIDs, hydroxychloroquine, azathioprine • C/I = cyclophosphamide, MTX (MUST STOP) • Taking PNV with 1mg folic acid SHx • Smoking/Etoh/Drugs FHx • Genetic/chromosomal/congenital anomalies • VTE/HTN

sexual issues history

HPI: ● Duration of problem ● What is the problem? o Desire o Arousal o Orgasm o Pain (coital pain, vulvar pain) & vaginismus ● Associated life changes with onset of problem (e.g. divorce/separation, death of partner, stress (personal/work), child-bearing, menopause, recent surgery, etc.) ● Intimate with male/female/both ● Menopausal Sx (hot flushes, night sweat, anxiety, concentration + memory difficulty, vaginal dryness), prolapse ● Relationship with partner, aroused by others? ● Partner's health, any problems with erection ● Use of sexual aids (porn, sex toys, dildo, etc.) ● Use of lubricants ● Masturbation ● Hx of physical, emotional, sexual abuse/rape ● Any investigation, therapy to date? ● How significant of a problem is it for this patient? is problem affecting day-to-day functioning? PMH: depression or other psychiatric disorders, DM, thyroid, HTN, CV dz, stroke, cholesterol, trauma (neurological injury), cancer PSH: pelvic surgery, vaginal surgery, BSO PGynH: ● LMP ● Menarche, cycles, dysmenorrhea, dyspareunia (deep/superficial), menorrhagia ● Paps, HPV vaccination ● Endometriosis ● Fibroids ● STIs/PID ● Contraception ● Hx of infertility PObH: # of deliveries, mode, operative vaginal deliveries, tears Meds (SSRI's, TCA, B-blockers, H2 blockers, anti-psychotics, thiazide diuretics spironolactone: decrease libido/desire) Allergies Habits: smoking, EtOH, drugs Social hx: social support ROS: ● Skin: vulvar disorder ● MSK: arthritis ● GU: dysuria, hematuria, UTI ● GI: constipation, diarrhea, melena

Hep B pregnancy history

HPI: ● Symptoms of acute hepatitis: fever, fatigue, nausea, vomiting, malaise, abdominal pain, anorexia, wt. loss, jaundice or change in urine/stool color (+ duration) ● Hx of hepatitis complications: bruising (r/o coagulopathy) or change in mental status (encephalopathy) ● Hx of recent travel to endemic area (Hep A & E) ● Is she vaccinated? Against which virus? ● Hx of known infected partner ● Previous Hx of acupuncture/ piercing / previous blood transfusion or needle prick Current Pregnancy: ● LMP ● Previous US & MSS results ● Amnio or CVS ● Previous admissions to the hospital ● Failure to gain wt during pregnancy PMH: ● Concomitant STIs (including HIV) ● Previous transfusions ● Anemia ● Liver disease ● DM ● HTN ● Autoimmune disease ● Dialysis ● Gallbaldder dz PSH: previous liver biopsy or organ recipient, cholecystectomy PObH: mode of delivery, birth weight, instrumentation, Apgars, sequelae on baby PGynH: STI including HIV, number of sexual partners, method of contraception used FxHx: liver disease in family, hx of HCC Meds/Allergies Social: ETOH, smoking, drugs (IV drugs)

amenorrhea physical exam

Height, weight, BMI Vitals General appearance - nutritional status, stigmata (turner's), anorexia (lanugo, carotenemia, parotid hypertrophy), PCOS (acanthosis nigricans, acne, hirsutism) Neuro exam - cranial nerves, visual fields, motor and sensory, absent smell Thyroid - goiter, palpation, hair and nail changes Abdominal exam - masses, hernias, scars, striae, tenderness Pelvic - external genitalia

Hirsutism physical exam

Height, weight, BMI Vitals - BP, HR, RR, temp General appearance Acanthosis nigricans Virilization - hair, baldness, acne, deep voice Muscle wasting Cushing's - truncal obesity, striae, moon face, buffalo hump, proximal weakness, hirsutism, acne Head and neck Thyroid, nodes Acne, hair pattern CVS, Resp - Breast exam if concern galactorrhea Abdomen Truncal obesity, scars, masses, hair (male eustacheon) Pelvic External genitalia - hair, estrogenization, clitoromegaly Speculum - vagina , estrogenization, cervix (paps and swabs) Bimanual - masses, uterus

forceps stations in pelvis

High (> 0) fetal head not engaged with station above ischial spines contemporary practice does not support the use of vacuum or forceps for delivery at high station Mid (0 to +2) fetal head no more than 1/5th palpable above the pubic brim per abdomen leading bony point of fetal skull is above station +2 cm but not above spines rotation ≤ 45 degrees from OA rotation > 45 degrees from OA (incl OP) Low (+2) leading bony point of fetal head at station ≥ +2 cm rotation ≤ 45 degrees from OA rotation > 45 degrees from OA (incl OP) Outlet fetal scalp visible at introitus without separating labia fetal skull has reached pelvic floor sagittal suture in anterior position or rotation < 45 degrees

pelvic stations

High (> 0) fetal head not engaged with station above ischial spines contemporary practice does not support the use of vacuum or forceps for delivery at high station Mid (0 to +2) fetal head no more than 1/5th palpable above the pubic brim per abdomen leading bony point of fetal skull is above station +2 cm but not above spines rotation ≤ 45 degrees from OA rotation > 45 degrees from OA (incl OP) Low (+2) leading bony point of fetal head at station ≥ +2 cm rotation ≤ 45 degrees from OA rotation > 45 degrees from OA (incl OP) Outlet fetal scalp visible at introitus without separating labia fetal skull has reached pelvic floor sagittal suture in anterior position or rotation < 45 degrees

maternal risks of TOLAC Which one has higher risk of death ?

Higher risks of ERCS - maternal death - maternal morbidity Higher risks of TOLAC - uterine rupture - PPH

diabetes anomalies

Highest odds (not most frequent) are 1) cardiac is common, specifically complete AV septal defect (ASD and VSD) others = coarc, tetralogy of fallot 2) neural tube defects hydrocephaly - most common anencephaly 3) renal cleft lip/ palate renal anomalies 4) MSJ The caudal regression syndrome.... which is - sacral agenesis (total absence of coccyx and total or distal absence of sacrum) AND associated with spinal cord anomalies, e.g. syringomyelia. • Musculoskeletal (15%) - caudal regression, sacral agenesis, limb reduction, club foot, polysyndactyly • Renal - agenesis, ambiguous genitalia

epithelial ovarian tumors

Histologic Classification of Epithelial Ovarian Tumors Serous - 46% Benign serous: >50% of all serous Serous borderline: 15% of all serous Low grade serous carcinoma: High grade serous carcinoma: 35-40% of all serous Mucinous - 36 % Benign mucinous: 80% of all mucinous Mucinous borderline: 10-15% of all mucinous Muncinous carcinoma: 10% of all muncinous Endometrioid- 8% Benign/borderline endometrioid Endometrioid carcinoma Clear cell- 3% Benign/Borderline Clear Cell <1% of clear cell tumors Clear cell ovarian carcinoma Transitional cell - 2 % Benign transitional cell Borderline transitional cell Transitional cell carcinoma Undifferentiated - 2% Mixed - 3 %

IUFD history

History - age, gravidity, parity, sure dates (early U/S, LMP) - when did this occur, how did you find out (decreased FM, U/S) - if remote, patient may be at risk for DIC/infection - any ctxns, rom, bleeding - OB/gyne hx (previous SA, SB, IUGR, anomalies), Med/Surg hx, meds, allergies, soc, fam hx (clotting disorder, hereditary conditions) itching? recent infections? fever/chills, nausea/vomiting? trauma?

vulvar pain history

History Demographics Age, relationship status, GTPAL When did it start Where is the pain Recurring or constant Dyspareunia Exacerbating factors - contacts (semen, urine, pads, clothing), allergens (soaps, lubricants, perfumes), trauma Alleviating factors - bath oils Treatments tried in the past - antibiotics, yeast treatements Related to menstrual cycle Character of pain - stinging, burning, irritation, rawness, pruritic, only to touch or all day (vaginismus vs vestibulitis), with sitting, all day activities, dysuria (interstitial cystitis, urethral syndrome, detrusor instability) Hot flushes/night sweats/mood changes - ?POF - atrophic vaginitis Bowel function - constipation vs diarrhea, mucous, blood, IBS Mood - anxiety, depression, stress Abuse - sexual, physical, verbal/emotional Sleep pattern Weight - esteem issues Past Gyne Hx: Menarche Menstrual history STI's Pap history Sexual history - number of partners, pain with previous relationship, desire, arousal, lubrication, orgasm, coitus, dyspareunia, concerns (dyspareunia - resulting in abstinence, decreased desire) Sexual function prior to onset of pain in comparison to now Pain exists with self-pleasure Does she have sexual fantasies PMHx: Diabetes Neurological disorders Chronic pain syndromes - arthritis, fibromyalgia, chronic fatigue syndrome Other major medical concerns depression ObHx: G0 Meds/Allg: antidepressants narcotics OCP / hormone therapy Social Hx: Relationship status, married, common-law Smoker Drug use EtOH School/work

how does endo CA spread?

How are Type 1 and Type 2 endometrial cancers spread? Type 1 - order of spreading ◻ Direct extension ◻ Lymphatic metastasis ◻ Hematogenous ◻ Intraperitoneal Type 2: simultaneous

baseline cardiac history pregnancy

How long has she has it. Symptoms (ie, NYHA class 1-4)- fatigue Syncope , angina, dyspnea, chest pain , cyanosis arrhythmia Cardiac echo/MRI Ejection graction Physical exam : left heart failure- symptoms (dyspnea, orthopnea, PND, fatigue , weakness and right heart failure = signs (edema, HSM, JVD)

DKA in pregnancy history

How sick she is, when did it Full infectious symptom history (head to toe) - fever - runny nose, congesion - sore throat - cough - chest pain - nausea/vomiting - diarrhea - dysuria, frequency, flank pain - sick contacts Age, G,P, LMP (Dates?) Travel, other precipitating events Sick contacts Any other concerns (ctx, bleed, ROM, FM) Preg'y invx to date: U/S, NT, screening PObsHx - hx IUFD, SA, congenital anomalies PM Hx Allerg Smoker, EtOH, Street Drugs Family Hx- DM Questions specific to diabetes: Duration of diabetes Insulin use/doses Diabetic complications: retinopathy, nephropathy, neuropathy, CV disease Hospitalizations for diabetes Episodes of DKA How well are sugars controlled (HbA1c) Episodes of hypoglycemia Who follows her (family MD, endocrine, cardiology, nephrology, ophtho)

manage cardiac disease in pregnancy

How would you manage this patient's pregnancy? · Multidisciplinary approach · Prepreg - MFM, cardiology · Early obstetrician/MFM, cardiologist, neonatology, genetics, nursing · Baseline EKG, echo, CXR · If critical AS - consider termination · Visits q2wks until 32 wks GA then weekly · Fetal echo · Serial U/S (r/o IUGR) starting at 26 weeks GA · Avoid things that é cardiac work - Anemia (Rx: iron) - Wt gain < 24 lbs - PIH - Infections (consider pneumococcal/influenza vaccines) - Limited physical activity (consider hospitalization prn) Cardiac meds as necessary (digoxin, diuretics, avoid nitrates or other vasodilators!)

HIV risk factors

Human immunodeficiency virus (HIV) •intravenous drug use •male sexual partner with HIV •male sexual partners who have had male-to-male sexual contact •sexual activity with multiple partners without using condoms •transactional sex •history of sexually transmitted infections in self or partners HIV transmission untreated HIV blood, semen, vaginal fluid

vulvar itch history/exam

Hx ● Age, LMP ● PMH o Graves, DM, SLE, achlorhydria/ pernicious anemia, derm ● PSH ● Gyne o Menstrual hx, menopause, sexual hx, dyspareunia, postcoital bleeding, contraception, Paps, STIs ● Obs o GTPAL ● Meds o Including topicals ● Allergies ● Social o Smoking, drugs, alcohol, occupation, ethnicity ● FH o Dermatologic conditions, autoimmune ● HPI o Duration, location, triggers (eg foods, enviro, meds), abnormal sensation, pain, dryness, discharge, hygiene, diarrhea, incontinence dyspareunia, use of soaps/ condoms/ pads/ tampons/ creams, excessive washing, prior treatment, affect on functioning • Associated vulvar symptoms: o Itch o Pain o Bleeding o Burning o Stinging o Feeling of rawness o Dampness o Vaginal discharge / odor • Associated systemic symptoms o Fever, chills, malaise, sore throat, cough, choryza, lymphadenopathy o Jaundice, hepatosplenomegaly • Infectious exposures o Sick contacts Px ● Vital signs ● General appearance, BMI ● HEENT o Thyroid, mucous membranes ● Breast ● Resp ● CV ● Abd ● Pelvic o Inspect, cotton swab probing for pain, lymphadenopathy, speculum, wet prep, pH, cultures, bimanual, neuro exam (perineal sensation, anal wink), vulvar biopsy, colpo ● Skin o Global, including oral mucosa & axillae

two types of hydrops

Hydrops fetalis = two or more fetal effusions- pleural, pericardial or ascites - or one effusion plus anasarca (general swelling) Usually accompanied by placentomegaly and hydraminos as it progresses. Clinically significant edema = sonographically > 5 mm skin thickness Clinically significant placentomegaly = sonographically placental thickness > 4 cm in the second trimester or > 6cm in the third trimester. Hydrops is divided into two categories: Immune hydrops occurs when the mother's immune system attacks and destroys the baby's red blood cells due to incompatible maternal and fetal blood types. This form of hydrops is uncommon today because of medication available to prevent the condition. Non-immune hydrops, the most common type, is caused by a fetal medical condition or birth defect that affects the body's ability to manage fluid. Up to 90% of all cases of hydrops today are non-immune hydrops.

figo staging GTN

I = confined to uterus II = adnexa/vagina III = pulmonary mets IV = liver, brain,other ¨ Lung (80% ¨ Vagina (30%) ¨ Pelvis (20%) ¨ Liver (10%) ¨ Brain (10%)

how to reduce need for assisted delivery?

IA over EFM if possible Dedicated support person for labor Manual rotation to OA if possible Oxytocin if poor contractions Possibly passive second stage

Post op day 2 cesarean chest pain/SOB history

ID: ● Age ● GPA ● Ethnicity PMH: HTN, DM, dyslipidemia, heart dz, kidney dz, autoimmune dz PSH: pelvic, abdominal surgery PObH: GA at deliveries, BW, mode of delivery, complications Recent pregnancy: prenatal care & pregnancy complications, C/S complications & reason, PP course PGynH: menses regularity, Paps, STIs FxHx: heart dz, HTN, DM Meds: anti-HTN, blood thinners Allergies Habits: smoking, ETOH, drugs Social: occupation HPI: ● Current symptoms related to SOB & chest pain o Duration/severity o Nature of pain: sharp, pleuritic, pressure o Precipitating/alleviating factors o Radiation of pain o Diaphoresis o Nausea/vomiting o Dizziness/syncope o Previous episodes ● Current PP-related symptoms o Abdominal pain o Bleeding o Wound Cardiac symptoms - swelling - worse when laying flat - heart beating fast or skipping beats - fatigue VTE - leg pain/swelling Preeclampsia - headache, RUQ pain

crohn / uc / IBD hx

ID: ● Age ● GPTLA ● Ethnicity ● Occupation Crohn's hx: ● Date diagnosed (age) ● Managing physician - regular follow-up? ● Frequency of flares, known triggers ● Treatment history o Medications o Hospitalizations ● Last flare: date, what clinical manifestations & treatments PMH: thyroid dz, DM, RA, DVT/PE, CT disease, SLE, other autoimmune conditions PSH POBH: pregnancies, SAB/TAB, complications (GH, PET, GDM, pneumonia, flares) PGynH Meds Allergies Habits: smoking, ETOH, drugs FxHx: SAB, RPL, fetal anomalies, consanguinity

dating twins

IVF- use conception date - When there is size discordance between the twins, gestational age can be estimated by: - using the biometry of the larger OR smaller fetus - using the average biometry of the 2 fetuses. The common clinical practice is to use the biometry of the larger twin, erring on the side of overestimation of gestational age, in order to avoid missing intrauterine growth restriction in the smaller twin. However, this overestimation may also lead to iatrogenic prematurity. n the first trimester, there is no significant difference in crown-rump length (CRL) discordance between monochorionic and dichorionic twins suggesting the same rule could apply to both. In the first trimester, many studies involving ART have shown that the size of the smaller twin has the best correlation to the known gestational age the foregoing discussion supports dating of twin gestation based on biometry of the smaller twin in the first trimester and the larger twin in the second trimester.

thrombocytopenia history

Identification: ● Age ● GPLTA ● Ethnicity HPI ● Bleeding - current? Location, amount, duration, color. ● Bleeding problems (bloody noses, cuts with prolonged bleeding, bleeding post dental procedures), menorrhagia ● Transfusions / severity of hemorrhagic problems ● Symptoms of anemia: fatigue, weakness, palpitations, dyspnea ● Symptoms of alcoholic liver disease ● Symptoms of autoimmune disease o Fatique, malaise, weight loss o Fever o Arthralgia, myalgia o Morning pain / stiffness o Peripheral joint pain / swelling: knees, wrists, shoulders, metacapophalangeal joints o Skin Nodules on extensor surfaces of forearms? RASH o SLE: malar rash, discoid rash, photosensitivity, oral ulcers, serositis (pleuritic chest pain/cough/sob) Current Pregnancy: LMP (date based on US/date) Serology results, US , MSS Any previous admission (bleeding, HG, Infections) Now: bleeding, CTX, Fetal mov General History: ● PMH: o Thrombocytopenia: gestational, autoimmune o Bleeding disorders, malaria o Clotting disorders / DVT / PE o SLE / APL/ connective tissue disorders o HTN, Pre-eclampsia, HEELP syndrome o Liver disease, alcoholism, Hepatitis C o HIV, hepatitis, Parvovirus ● PSH o If surgeries, any problems with bleeding ● POBS o GPLTA -? complications (Pre-eclampsia, HTN, HELLP) o Antenatal bleeding, PPH ● PGYN o Menarche, cycle regularity, menorrhagia o Recurrent miscarriages o Any know gyne problem ● Habits: alcohol, IV drug use / needle sharing, sex trade ● Family history o Bleeding disorders o Bleeding problems / bruising / transfusions o Alcoholism ● Allergies: ● Medications: Unfractionated Heparin, LMWH

t1DM history

Identifying • Age, GTPAL • LMP Diabetes history • Onset, duration (how many years) • Who does she receive care from o Endocrine, FamMD, nurse, dietician, nephro, ophtho etc. • Control o How often does she check sugars o Usual range o Highs and lows o DKA episodes, when? • Most recent HbA1C • Insulin regimen • Complications o Microvascular - nephropathy, neuropathy, retinopathy o Macrovascular - HTN, CAD, Cereberovascular, peripheral vascular • Recurrent infections o UTI's, candida, skin • When are you hoping to conceive? Meds • Insulin • Antihypertensives -ACEi/ARB? • Oral hypoglycemics • Folic acid, multivitamin • Other PGynehx • Menarche, menstrual pattern and regularity • Contraception • Dysmenorrhea, intermenstrual or postcoital bleeding • STI's, Paps, PID • Surgeries PMedhx • Thyroid • Autoimmune • Hyperlipidemia • HTN, CAD etc PObhx • Year, complications antenatal and postpartum, GA at delivery, type delivery, pp complications, birthweight PSurghx - laser eye etc. Family history • Diabetes, thyroid, genetic, chromosomal, developmental delay, anomalies, neural tube defects Social • Smoking, drugs, alcohol, marital status, occupation

Hyperemesis history

Identifying criteria ● Age, GPTLA ● Ethnicity, occupation ● Medications ● Allergies Pregnancy history + HPI: ● Planned pregnancy ● LMP, Estimated GA (Menses regular lately, Dating U/S), MSS ● Symptoms : HA, fatigue, abdo pain, PVB, cramps ● N+V : how many times a day, aggrevating/ alleviating factors, any antinausea meds ● Symtpoms of hyperT : heat intolerance, diharrea, mood disturbance, tremors ● Drug abuse ● Weight loss, what's her prepregnancy weight ● Can she keep any food down (solids/ liquids) ● How many times a day does she void if at all ● How's her energy level. Is she working? Any children at home to take care of? ● Mood disorders, depression, why is she fatigued ● Signs of dehydration : dry cracked lips, dry skin General Review of Systems / Medical History ● PMH: Thyroid, diabetes, RA, DVT/PE, connective tissue disease, Crohns/UC ● PSH: abdominal sx ● pOBS: o Pregnancy history: pregnancies, SAB/TAB, RPL? ● GYN: periods regularity, duration, bleeding, intermenstrual spotting, dyspareunia, last pap, any abnormal paps, hx of STIs, what contraception method was she using ● Habits: smoking/etoh/drugs ● Family History o Thyroid disorders o Consanguinity

first trimester bleeding HX

Identifying data • Age • GP status HPI • Bleeding o How much o Onset o Passage of tissue o Instigating event (IC, TVUS, vag exam) o Associated pain • Current pregnancy o How it was confirmed o Previous bhcg o Previous u/s POBHx • Details of previous pregnancy PGynHx • Pap history • STIs/PID • IUD use PMHx/PSHx • Medical • Any abdominal/pelvic/tubal surgeries FHx • Meds/All • Folic acid (0.4-1mg) • ?expoxsure to teratogens Soc Hx • Smoke/EtOH/drugs

causes of RPL

Idiopathic Advancing age hormonal factors (diabetes, hypothyroid, hyper-prolactin) genetic factors: abnormal parental karyotype (most common = balance reciprocal, also robertsonian, Turner's Mosiac ) abnormal egg karyotype (ie, higher w/ advancing age) anatomic factors- (septate.... less so bicornuate and arcuate) - submucosal fibroids - polyps - adhesions (ie, ashermans) Infections (chronic endometritis) APS, ...maybe thrombophilias (less convincing) male factor (abnormal sperm)

varicella exposure management

If immune- nothing needs to be done If not immune - VariZIG - alternative is oral acyclovir for VariZIG, obtain informed consent (blood product) Avoid contact with the child , arrange for child care Monitor for symptoms (rash, viral symptoms, or pneumonia like chest pain, SOB) Follow on ultrasound for findings of congenital varicella

manage uterine inversion

If the uterine inversion occurs before separation of the placenta, it is important that the placenta be left in situ, as manual removal or separation of the placenta will lead to additional hemorrhage. Management involves - maternal hemodynamic stabilization with fluid - replacement of the uterus to its proper orientation. Replacement often requires uterine relaxants such as -nitroglycerin - halogenated anesthetics - terbutaline - magnesium sulfate. Once the uterus is relaxed, manual pressure is applied internally to reposition the uterine fundus. After repositioning, uterotonic agents should be administered to control maternal bleeding and prevent recurrence of the inversion.

varicella exposure workup

IgG (throw in IgM) if immune, nothing needs to be done

diagnose maternal toxoplasmosis

IgG antibodies usually appear within two weeks of infection and persist in the body indefinitely. IgM antibodies often remain positive for up to one to two years. A positive IgM antibody test result at any time does not necessarily mean the infection was acquired recently; ......this needs to be confirmed at a reference laboratory. Only approximately 22%-40% of positive IgM results obtained at nonreference laboratories in the United States are deemed to have had a recent acute infection If IgG negative and IgM negative, this indicates the absence of infection or extremely recent acute infection. positive IgG and negative IgM , this indicates an old infection (infection greater than 1 year ago). IgG positive and IgM are positive this indicates either a - recent infection - false-positive test result - pastinfection - Repeat this in 2-3 weeks The Sabin-Feldman dye test (SFDT) is still considered the "gold standard". It detects the presence of anti-TG-specific antibodies (total Ig). The absolute antibody titer is also important: values over 250 IU/mL are considered highly suggestive of recent infection. Maternal infection is diagnosed by sending maternal serology to a reference laboratory ..... It is best to make the diagnosis based on two different serum specimens collected at least four weeks apart. Usually, the reference laboratory reports serologic results with a high possibility of infection if there is the following: • Seroconversion during pregnancy • Increase in both specific IgG titer (>3-fold) and dye test titer (>3-fold) • Presence of specific IgM and dye test ≥300 IU/mLv In recent decades, Toxo IgG avidity assay has been used as a standard diagnostic technique for a better estimation of the infection acquisition time and identification of the primary T. gondii infection during pregnancy. Avidity is described as the aggregate strength; by which, a mixture of polyclonal IgG molecules reacts with multiple epitopes of the proteins. This parameter matures gradually within 6 months of the primary infection

risk of epidural What are side effects ?

In cephalic labour, epidural analgesia increases the need for oxytocin augmentation impairs maternal pushing efforts prolongs the second stage increases the need for assisted vaginal birth. Side effects: - hypotension (sympathetic blockade causes vasodilation and low venous return) - fever - shivering - urinary retention - pruritis

why are monochorionic twins dangerous?

In contrast to fused dichorionic placentas, almost all monochorionic placentas (>95%) exhibit intertwin vascular anastomoses crossing the intertwin membrane vascular communications between monochorionic twins can be artery-to-artery (AA) vein-to-vein (VV) artery-to-vein (AV) AV anastomoses are obligatorily unidirectional. AA and VV anastomoses are bidirectional and allow flow in either direction, depending on pressure gradients between twins.

thyroid changes in pregnancy

Increased vascularity Glandular hypertrophy Increased TBG by the liver Increased total T4 (but free T4 and T3 should usually be the same) Decreased TSH (T1), but then back to normal · Serum iodide drops because of increased excretion and uptake by the placenta for the fetus, the thyroid increases its iodide uptake from the blood to compensate and 15% will have clinically enlarged thyroid that resolves postpartum

What are the sequelae of PCOS that you would want to counsel the patient about?

Infertility - anovulation, SA/RPL Endometrial pathology - hyperplasia/carcinoma (elevated estrogen, insulin, testosterone) Hirsutism Metabolic syndrome/cardiovascular risks Ovarian torsion Type II DM - 2-5x risk Associated with age, BMI, waist to hip ratio, family history

Thioamides

Inhibit thyroid peroxidase which is the rate limiting step of thyroid hormone synthesis from iodine PTU also decreases T4 into T3

respond to tachysystole

Initiate BEFORE the 30 mins (after 10 mins) continue EFM stay with patient Reduce or shut off pit.... or remove prostaglandin assess for abruption Notify staff, anesthesia, NICU, charge nurse Consider tocolysis (nitroglycerin)

hematuria ddx

Interstitial cystitis Recurrent UTI Chemical cystitis/urethritis: cyclophophamide, radiation Infectious vaginitis/urethritis: Chlamydia, gonorrhea, myoplasma, ureaplasma, bacterial vaginosis, genital herpes, tuberculosis Urethral diverticulum or prolapse Endometriosis Bladder carcinoma or carcinoma in situ Primary or Recurrent genital tract malignancy: vulva, vaginal, cervix, endometrium Urolithiasis

side effects of Mirena

Irregular bleeding Infection perforation expulsion imbedding pain, dysmenorrhea cysts breast tenderness

secondary syphilis

It generally begins with a nonspecific constitutional ill ness that commonly includes a sore throat, low-grade fever, myalgias, and generalized lymphadenopathy. • Skin rashes are the classic and most commonly recognized lesions, but the appearance is highly variable, and differential diagnosis is often challenging. • Rash is often initially macular and nonpruritic and becomes papular by three months. • Rash frequently involves the palms of the hands and soles of the feet, and may be accompanied by mucous patches in the mouth, pharynx, or cervix and condyloma lata in the anogenital region or axilla. Condyloma lata are hypertrophic lesions resembling flat warts that occur in moist areas. • Individuals are highly contagious during this stage, especially upon contact with mucous patches or condyloma lata. • Secondary disease lasts for an average of 3.6 months and spontaneously resolves. Approximately 25% of individuals experience a relapse of secondary disease during the first year of infection.

opioid withdrawl preterm labor management

Admit the patient .................................................................. ___/1 Advise patient on need to stop illicit opiod use ................................. ___/1 1. Symptomatic treatment • Antiemetic ...................................................................................___/1 • Anti-diarrheal agent ................................................................ ___/1 • IV hydration ...............................................................................___/1 • Pain medication for myalgias....................................................___/1 2. Start therapy for opioid withdrawal-opiod substitution therapy is preferable to medication-assisted withdrawal (detoxification) because it is safe and associated with a lower rate of heroin use .....___/2 • Methadone ...................................................................................___/1 • Buprenorphine ............................................................................___/1 • Buprenorphine/naloxone ...........................................................___/1 • ***Need special methadone license for this. Can get emergency one if needed but will need help with the dosing from a methadone physician ....................................................___/2 3. Fetal testing dependent on gestational age for fetal well-being - U/S 4. Consider protection concerns - social work consult ...........................___/1 5. Consider addiction medicine consultation ............................................___/1 6. Peds consult - neonatal withdrawal issues.............................................___/1 7. Anesthesia consult for anesthesia in labour .........................................___/1 8. STI testing..................................................................................................___/1

rubella transmission mechanisms

Adults: Respiratory droplet, then hematogeneous dissemination through the body Vertical crosses placenta by hematogenous spread

risks for placenta previa

Advanced maternal age Multiparity Multifetal gestation Smoking Prior C-section

what are advantages of TVT vs Burch What are disadvantages ?

Advantages: o As effective as Burch and suburethral slings o Fewer complications (bleeding, infection) o Less voiding dysfunction o Shorter hospital stay o As effective as Burch for recurrent SUI and ISD o Less surgeon-skill dependent o Less anesthesia requirement Disadvantages: o Higher rate of bladder perforations (6%) o Higher risk of bowel injury o Risk of mesh erosion (1%)

) Assuming the diagnosis is ovarian torsion, what elements of this patient's history are important for surgical planning?

Age (menopausal or not) LMP, contraception, parity Past medical history: endometriosis, PID, radiation Past surgical history: abdominal surgeries When the patient last ate and drank

Gyne history

Age of puberty order LMP Cycle frequency, duration, heavy, IMB, PCB Dysmenorrhea ? Pain with bowel? bladder? intercourse ? Pap? Sti? Social hx contraception partners

maternal side effects of PTU

Agranulocytosis drug like lupus syndrome (rash Vasculitis , arthralgias, itching, thrombocytopenia, ) Liver elevation

Ballantyne syndrome

Aka 'mirror syndrome' - is a syndrome where fetal hydrops can be related to maternal edema and the development pre-eclampsia. Triad of - fetal hydrops - maternal edema - placentomegaly

Second stage exhaustion station. You are consulted by a MW... what do you want to know ?

All about patient Age, vitals , height, weighth PMHX, meds, PsHX, allergies, social hx, fam hx (bleeding OB hx GTPAL dating, pregnancy care. eFTS, anatomy scan GDM, ultrasounds. GBS Labor progression, oxytocin ? How she has been pushing? well or not well? analgesia? Position ? Then I would: - review the tracing - examine the patient (VE, ultrasound for position, station) - assess contraction patern - assess analgesia - watch her push

Vaginal bleeding in pregnancy

Amount of bleeding Painful, painless bright red, dark red Clots contractions Other questions (LOF, fm) provoking factors (ie, trauma, intercourse) Pap gardasil General hx PMHX, surg, meds, allergies, social hx, OB hx Dating serologies Rhesus CBC, ABO T&S Kleihauer Fibrinogen Pt/ PTT

hyperthyroid labs

Antenatal bloodwork if not complete CBC, G+S EKG TSH, T3, T4 Thyrotropin receptor antibodies Urine culture, cervical swabs as necessary Fetal ultrasound

high risk factors with placenta previa or low lying placenta

Antepartum bleeding - if it happens early (< 30 weeks) - 3+ bleeds - Short cervix - previous CS - accreta - thick placental edge - marginal sinus)

adnexal mass in post menopausal hx

Any symptoms § Pelvic or abdominal pain ................................................... Acute or chronic? ...................................................... § Bloating, abdominal fullness § Urinary urgency/frequency ................................................ § Difficulty eating/feeling full .............................................. _ § Bowel symptoms ............................................................ § Abnormal vaginal bleeding . .............................................. § Shortness of breath § Dyspareunia ð Past Gyne hx Menopausal status & LMP ......................................................................................___/1 § History of cysts/masses .................................................... § History of endometriosis § History of infertility .................................................... § Last pap and pap history .................................................... § Menarche/menopausal ages ................................................ § Use of OCP ever ............................................................. § Use of HRT ever ............................................................. ðOther medical History Past Ob Hx ð PMH ... ð PSH ð Meds ... ð Allergies ð Family history § Ovarian Ca .......................................................................... § Breast Ca § Endometrial cancer... § Colorectal Ca... § BRCA 1 or 2 gene mutation § Lynch syndrome v ð Social history § Who does she live with? .................................................. § Professional/occupational history ........................................ § Etoh ........................................................................... § Drugs ......................................................................... _ § Smoking ......................................................................

parvovirus frequency and consequences of fetal infection

Approximately 25-30% of fetuses of mothers with primary parvovirus B19 infection will become infected themselves through vertical transmission. Of these, 80-95% will have no sequelae and 5-20% will develop fetal anemia. In most cases, the anemia is transient...... Overall, approximately 2-10% of fetuses with parvovirus B19 infection will develop hydrops fetalis. The likelihood of hydrops fetalis substantially increases when maternal primary infection occurs at less than 20 weeks' gestation 1st trimester - the risk of hydrops varies from less than 5% to approximately 10%. 2nd trimester- therisk of infection decreases to 5% or less. I> 20 weeks, the risk of fetal hydrops is 1% or less. Epidemiological studies do not support the association between parvo virus B19 infection and congenital malformations. This can cause: Transient, isolated pleural and pericardial effusions are thought to be secondary to direct inflammation. - miscarriage - stillbirth - severe fetal anemia - myocarditis, - hydrops - fetal death.

types of maternal HSV

Ask if history of previous genital HSV - Primary infection occurs when the individual encounters either HSV-1 or HSV-2 and has no prior exposure (i.e., HSV-1 and HSV-2 antibody negative) to either viral type. - Non-primary first episode is the first clinically recognized episode, but the individual has HSV-1 or HSV-2 antibodies from a prior exposure. - Recurrent infection is clinically evident infection in an individual with antibodies to that virus.

intraop borderline tumor management

Assess the upper abdomen and pelvis for any abnormalities run the bowel assess the appendix (which appears normal), assess the opposite ovary for any cystic changes and assess fully the peritoneum.

should women take HRT ?

MHT can be safely initiatedin healthy women without contraindications who are 1) younger than 60 years of age 2) less than 10 years post-menopause The estrogen component serves to alleviate bothersome symptoms, whereas the progestogen component provides protection against the increased risk of endometrial cancer seen with estrogen alone Estrogen-related adverse effects include nausea fluid retention breast tenderness headaches ● Individual decision ● Weigh severity of symptoms & individual RF analysis ● If take HRT, take at lowest effective dose & for shortest possible time (re-evaluate yearly) ● Indication: for Rx of vasomotor sympoms

lynch syndrome genes

MLH1, MSH2, MSH6, PMS2

what are risks and benefits of a stretch and sweep ?

Main risk is either: 1) patient discofort 2) failure - works around 1 in 7 to prevent delivery by the due date 3) could be some risk of ROM 4) will likely cause some minor spotting- but has not been shown to cause serious bleeding benefits: May promote low level uterine activity and some aspect of cervical ripening, and potentially labor to prevent the need for post dates IOL and complications

male infertility history

Male history Identifying data • Age • Previous paternity PMedhx • Cancer, chemo or rads • DM • Thyroid • Vascular disease, HTN PSurghx • Abdomen, pelvis • Groin, testicle Testicles history • Undescended • Injuries • Torsion • Orchitis, mumps • STI's • Surgery - torsion, hernia etc • Varicocele Sexual history • Erection, ejaculation, desire Meds Allergies Social/occupational • Hot tub, sitting a lot • Tight pants • Smoking, alcohol, marijuana • Sports • Occupation Family history as above - genetics, chromosomal, anomalies, infertility in men

Risks of Twin Pregnancy compared to singleton

Maternal risks - hyperemesis - anemia - cardiac complications - HTN , preeclampsia - diabetes - VTE - AFLP - PUPPS - Cesarean - PPH - abruption Fetal risks - miscarriage - anomalies - preterm birth - complications of preterm birth (ROP, RDS, NEC, IVH, DIE) - growth restriction - stillbirth - PPROM

maternal risks of hyperthyroid pregnancy

Maternal risks - mainly if poorly controlled disease - Thyrotoxicosis and thyroid storm - weight loss - dehydration - Preeclampsia, gestational hypertension - arrhythmia - CHF- heart failure from cardiomyopathy - Abruption - PTL

risks of being post dates

Maternal risks: Shoulder dystocia Gestational HTN Birth trauma causing maternal pain PPH Fetal Risks: IUFD placental insufficiency Post maturity syndrome Decreased Apgars Meconium Aspiration Syndrome Decreased cord pH NICU admission Increased seizures Oligohydramnios Increased developmental abnormality at 5yrs old Shoulder dystocia Brachial plexus injury

sickle cell pain crisis

Maternal vital signs. • Supplemental oxygen to maintain saturations >95%. • Aggressive fluid resuscitation. • Initial laboratory testing: type and screen, CBC, reticulocyte count, LDH, haptoglobin, urinalysis, urine culture. • Investigation of precipitating cause (infection, dehydration, severe anemia, etc.). • If oxygen desaturations or chest pain are present, then obtain chest x‐ray to evaluate for acute chest syndrome. Provide adequate analgesia; opiates are often mainstay of therapy and continuous infusion/patient‐controlled anesthesia may be necessary. • VTE prophylaxis while in crisis. • Fetal assessment with fetal heart tones if previable or nonstress test if viable. • Antenatal steroids for evidence in the setting of nonreassuring fetal testing. • Empiric antibiotics if infection or acute chest syndrome is suspected. • Multidisciplinary care approach with hematology consultation. Consider exchange transfusion

HTN/headache physical exam

Maternal: ● BMI ● VS - BP readings, HR, SaO2, temp ● H&N (visual fields) ● Cardiorespiratory ● Abdominal o RUQ tenderness o SFH o Palpable contractions ● Vaginal exam - cervical dilation/effacement/position/firmness ● Extremities o Reflexes, clonus o Oedema

consequencs of amenia in pregnancy

Maternal: ● Frequent hospital visits depending on underlying etiology, e.g. SCD, thalassemia ● PTD: preterm delivery. ● Increased maternal mortality ● Increased need for blood transfusions ● Increased risk of PP depression Fetal: ● FGR, SGA ● Prematurity ● Decreased psychomotor performance in offspring

meds and urinary incontience

Meds: anticholinergics, alpha blockers, ACE inhibitors, calcium channel blockers, diuretics, sedatives, narcotics, NSAIDS, antipsychotics, HRT, oral contraceptives, radiation treatments

menopause history

Menopausal symptoms • Menstrual pattern o Last period, one before that? o Duration menopause o Cycles irregular/regular, bleeding between o Any bleeding since the LMP • Hot flushes o Frequency, severity • Difficulty sleeping • Night sweats • Mood lability, irritability - memory issues • Depression • Decreased energy • Decreased libido • Vaginal dryness, irritation, infections • UTI's • Urinary incontinence - urgency, frequency, nocturia, SUI • How are symptoms affecting overall life? • Endocrine symptoms o Weight loss/gain, tremor, anxiety, bowel changes, skin or hair changes Sexually active • Dyspareunia • Post-coital bleeding • Libido PGynehx • Menarche, menstrual history • Pap smear and any abnormal • STI's • Gyne surgeries - hysterectomy, BSO, D&C • Sexually active • Contraception history PMedhx • CAD • HTN • Hyperlipidemia • DM • Liver disease • VTE, thrombophilia • Stroke • Breast cancer • Fractures • Thyroid disease • Hematologic disease, leukemia, lymphoma • Autoimmune disease • Preventative health: mammogram, BMD, colonoscopy Meds • Vitamin D/calcium - how much • Ever been on steroids? • Herbal remedies/CAM's Allergies PObhx Familyhx • Cancers - Breast, endometrium, colon, ovary, other • CAD • DM • VTE • Osteoporosis/fracture Social • Smoking • Alcohol • Drugs • Caffeine • Exercise • Diet

missed pill algorithm

Miss 1 pill but remember within 24 hours- just take a bonus pill ASAP and go back to regulr time Miss 1 pill in general take 1 ASAP, then take 1 daiy miss 2 or more: Take a pill immediately.... - consider EC if had intercourse during the last few days - use backup contraception (condoms) for 7 days - skip the hormone free pills and keep taking active hormone all the way until through another cycle

CMV infection

Most common congenital infection It is a HERPES virus, so it can remain latent Clinical findings — ASYMPTOMATIC in approximately 90% of cases. The incubation period ranges from 20 to 60 days, after which a mild mononucleosis-like syndrome ensues lasting 2 to 3 weeks -fever - headache - rhinitis - sore throat - LAD - malaise , high lymphocyte count, and abnormal liver enzyme results. Rare complications include hepatitis Guillain-Barré syndrome - and myocarditis CMV mononucleosis can be accompanied by dermatologic manifestations in approximately one-third of patients including macular, papular, maculopapular, rubelliform, morbilliform, and scarlatiniform eruptions. Non-primary CMV reactivation of endogenous (latent) virus, or re-infection from another CMV strain

Rubella findings in a newborn

Most common effect of rubella vertical transmission is FGR Classic triad: - sensory-neural deafness - eyes congenital cataracts (white pupils) or retinopathy - Cardiac= PDA most common, (but supravalvular pulmonic stenosis is perhaps the most pathognomonic. ) - CNS defects - deafness (affecting 60% to 75% of fetuses) - eye defects (such as cataracts or retinopathy) (10% to 30%) - CNS defects (10% to 25%) - cardiac malformations (10% to 20%). The most common cardiac abnormality is PDA, - mental retardation, pneumonia - low birth weight In addition, there may be severe disease during the newborn period - including thrombocytopenia - bleeding - hepatosplenomegaly - pneumonitis - myocarditis.

high spinal- how to manage?

Most often, high or total spinal blockade follows: - administration of an excessive dose of local anesthetic - inadvertent injection into the subdural or subarachnoid space. Subdural injection manifests as a high but patchy block even with a small dose of local anesthetic agent, whereas subarachnoid injection typically leads to complete spinal blockade with hypotension and apnea. The signs and symptoms include a rapid ascending sympathetic, sensory, and motor block with associated: - bradycardia - hypotension - dyspnea - difficulty with swallowing or phonation. Symptoms can progress to unconsciousness (due to brainstem hypoperfusion and/or brainstem anesthesia), and respiratory depression (secondary to respiratory muscle paralysis and brainstem hypoperfusion). These conditions must be immediately treated to prevent cardiac arrest. In the undelivered woman: (1) the uterus is immediately displaced laterally to minimize aortocaval compression; (2) effective ventilation is established, preferably with tracheal intubation (3) intravenous fluids and vasopressors are given to correct hypotension. If chest compressions are to be performed, the woman is placed in the left-lateral position to allow left uterine displacement.

when can you perform fertility preservation in endometrial cancer?

Must be -Grade 1 endometrioid -stage 1 (preferably 1A) - PR positive Treat via high dose progestins (IUD, Megace Put on a high dose progestin, repeat sampling q 3 months Hyst if no response by 12 months

effect of opioids on NST/BPP

NST: decreased beat to beat variability, suppress fetal heart rate accelerations ....................................................................... ___/2 BPP: decreased fetal movements, suppress fetal breathing .................. ___/2

Amsel Criteria

Need 3/4: 1. Fishy odor with addition of KOH 2. Vaginal pH >4.7 3. Clue cells on wet mount 4. Thin, homogenous, grey discharge

neonatal consequences of opioids

Neonatal abstinence syndrome - NAS .......................................... ___/1 This may take 24-72 hours to present itself if on methadone or other long term opioid .................................................................... ___/1 May want neonate hair or meconium testing for drugs of abuse ............ ___/1

criteria for breech delivery (contraindications)

No contraindication to vaginal delivery (ie, cord prolapse or cord presentation, placenta previa) Weight: 2500/2800 - 4000 g (avoid growth restriction and CPD) (has to be either complete or frank) .... cannot be footling Clinically inadequate maternal pelvis (weak; very low) Cannot have - Fetal anomaly likely to interfere with delivery - Hyperextended fetal head (weak; low) Should also have: -Center with a skilled obstetrician comfortable with breech delivery - center able to perform urgent cesarean - Preferable to have adequate analgesia (in that case) - Anesthesia and pediatrics there for the delivery - Continuous EFM in labor SOGC says: - consider passive second stage for up to 90 minutes - Delivery should be at least imminent within 60 mins of pushing You can use oxytocin

ways to prevent surgical site infections

Optimize medical conditions Improve anemia Improve glycemic control Pre op antibiotics normothermic normoglycemia chlorhexidine Sutures vs staples Clippers on hair before- no shaving

signs of uterine rupture

Other Signs of Uterine Rupture Classically, other signs and symptoms of uterine rupture include FHR changes •Vaginal bleeding • Acute onset of scar pain or tenderness (seldom masked by an epidural; Other signs and symptoms may include •Hematuria •Maternal tachycardia, hypotension, or hypovolemic shock •Easier abdominal palpation of fetal parts •Unexpected elevation of the presenting part •Chest pain, shoulder tip pain, and/or sudden shortness of breath •hA change in uterine activity (decrease or increase) is an uncommon and unreliable sign.

hyperemesis exam

Overall appearance: nutritional status (thin?), pallor? Vital Signs: BP, pulse, T, RR, 02-sat, Pain scale (if applicable) Urine output / color HEENT: ● Anemia: pallor ● Neck exam for thyroid gland enlargement ● LN ● Mouth: dry cracked lips ● Ketone odour CVS + RESP ABDOMEN ● Tenderness ● Uterine size EXTREMITIES ● LL swelling SKIN: turgor, rashes NEURO Motor / sensory losses? Deep tendon reflexes (electrolyte disturbance)

SLE physical exam

Overall appearance: nutritional status (thin?), pallor? Vital Signs: BP, pulse, T, RR, 02-sat, Pain scale (if applicable) Urine output / color (if lupus nephritis) HEENT: ● Malar rash ● Discoid rath ● Anemia: pallor ● Oral ulcers ● Thyroid - enlargement / nodules ● Lymphadenopathy ● Acanthosis nigricans CVS ● Heart sounds: S1/2, murmers?, S3/4, rub? RESP: ● Bilateral air entry? Dullness? Rub? ABDOMEN ● Tenderness ● Discoid rash? ● Lymphadenopathy ● Hepatosplenomegaly EXTREMITIES ● Pitting edema? ● Rash? Discoloration (arterio-venous insufficiency?) NEURO ● Motor / sensory losses? Deep tendon reflexes

how does EC work ?

Overall goal is to prevent implantation Plan B/ OCP- thickens cervical mucus - prevents the sperm migrating Plan B/OCP: prevents ovulation May alter endometrial receptivity Copper IUD - copper ions toxic to sperm - foreign body reaction

perimenopausal bleeding exam and workup

P/E: · Vitals (Orthostatic changes) · H&N: Petechia, conjunctival pallor, LN's · Limited CV/Resp (heart, lungs) · Abdo: masses, ascites (shifting dullness, percussion) Supraclavicular nodes · Pelvic: o Inguinal LN's o External genitalia: vulvar lesions o Speculum: polyps, ectropion, lesions, atrophy, Pap o Bimanual: uterine enlargement, adnexal masses Pelvi-rectal exam Invx: · CBC · BHCG · Ferritin · TSH · PRL · ?LH, FSH · Estradiol. Progesterone · Coags · Endom'l Bx · Pap · Pelvic U/S SIS for polyp!!!

itching in pregnancy exam

PHYSICAL EXAM ● VITAL SIGNS & BMI ● General appearance: jaundice? Ill? Level of consciousness ● Skin: o RASH o stigmata of liver disease (jaundice, sclera icterus, spider angioma, telangectasias, caput medusa, clubbing, palmar erythema) o Lymphadenopathy (infection) ● Abdomen: hepatosplenomegaly, ascities ● Neurological findings: o Asterixis (jerky, rhymical tremor) o Reflexes ● Fetus: NST

name indications for induction

PPROM near term Term PROM Chorio Preeclampsia at term eclampsia HELLP AFLP GDM T2DM AMA Multiple pregnancy growth restriction abnormal doppler Cholestasis Cardiac issues

PID history

Pain characteristics - site, onset, characteristics , radiation, alleviating,exacerbating, severity Gyne Hx Bowel/bladder Discharge Bleeding Cramping Gyne Hx Sexual history LMP contraception condoms

partial mole ultrasound

Partial hydatidiform moles may present as - an empty gestational sac - a sac containing amorphous fetal parts - growth-restricted/nonviable fetus - There is decreased amniotic fluid and an enlarged placenta relative to the size of the uterus, with cystic spaces often referred to as having a "Swiss cheese" appearance. The gestational sac in the partial hydatidiform mole may have an ovoid appearance, as determined by an increased transverse diameter (ratio of transverse diameter to anteroposterior diameter >1.5).

etiology of cervical insufficiency

Passive and painless dilation of the cervix during the second trimester May be either idiopathic acquired congenital congenital- uterine anomalies acquired- HPV infection invasive procedures (leep, cone) trauma (ie, laceration) overdistension (twins ,polyhydramnios)

Post op questions for pelvic pain and fever

Patient history: Onset of symptoms Pain: location, duration, quality, severity, radiation Fever, nausea, vomiting, diarrhea Dizziness, weakness Shortness of breath, chest pain Infectious symptoms : dysuria discharge, abdo pain, cramping diarrhea N/V Cough, runny nose heart Date of surgery Procedure done Reason for surgery Pre-operative risk factors: - -anemia- -infections: urinary tract infection (UTIs), bacterial vaginosis, pelvic inflammatory disease Past medical history (Pmhx): diabetes, anemia Surgical history (Shx): previous surgeries Information from patient chart: intraoperative or postoperative complications -administration of prophylactic antibiotics - hemorrhage/ transfusion -Injury bowel or urinary tract, vessels -postoperative ileus -postoperative hematoma OR note (size of fibroid uterus, technique used, thermoelectric instruments, morcellation estimated blood loss)

Patient is blood type A negative , with bleeding , how would you council ?

Patient is negative for the D antigen In some circumstances, there can be a mixing of maternal/fetal blood, and in subsequent pregnancies this can cause formation of maternal antibodies against future babies that are also Rhesus negative. This can cause alloimmunization, which causes fetal anemia , possible heart failure, hydrops, fetal death In this circmstance, she needs Rho-gam, ideally within 72 hours. This significantly reduces the rate of rhesus incompatibility Ideally, otherwise we can : - check paternal serology .... If Rh neg mom, and paternity is certain, with dad is known Rh neg also, then impossible the baby is Rh +.... Cell free DNA can screen for fetal Rh status.

methotrexate requirements

Patients selected for methotrexate treatment must be - clinically stable without signs of acute intraperitoneal bleeding or tubal rupture - must not be experiencing significant abdominal pain - must be able to understand the proposed treatment - must accept the potential risk of failure - must be able to access to emergency care - must agree to follow-up to monitor response to therapy. In addition, they must not have any absolute contraindications to methotrexate that make administration of the drug dangerous.

treat low risk GTN

Patients with stage I disease who have completed child-bearing can be offered hysterectomy, although systemic therapy may still be required if post-surgery monitoring demonstrates persistent disease. A recent retrospective study showed that 82% of women with low-risk, nonmetastatic GTN treated with hysterectomy did not require salvage chemotherapy. Patients aged 35 years and younger with a modified WHO prognostic score of ≤4 can also be offered a second curettage. This approach may spare over 40% of patients the need for chemotherapy and has a low incidence of complications such as uterine perforation or acute hemorrhage. The impact from this approach on future fertility is unclear, and concerns have been raised about the risk of uterine synechiae with a second procedure. In the event of drug resistance, restaging and risk scoring will: a) prompt a switch to an alternate single-agent (revised risk score ≤6) or b) multi-agent treatment. Therapy is continued until serum hCG levels normalize, followed by 2 to 3 cycles (4 to 6 weeks) of consolidation Cure rates around 100%

LeFort Colpocleisis What must you have before?

Performed with uterus in situ ☐ No concomitant hysterectomy if uterus normal (reduces morbidity of surgery) ☐Need pre-operative evaluation of uterus / endometrium with pelvic U/S or endometrial biopsy, and history of normal paps

heavy menstrual bleeding history

Period history ? (frequency, duration, color of blood) -Clots? - flooding? IMB? Gyne Hx? any easy bruising ? nose bleeds? Brushing teeth ? rectal bleeding ? teeth extractions/surgeries? Family hx? Sympthons of anemia (fatigue, palpitations, weakness)

ectopic physical exam

Physical Postural Vitals (BP, pulse, RR, O2sat, temp), Ht/Wt CV, resp Abdominal exam - distention, Cullen's (ruptured ectopic), Gray-Turner's - peritoneal signs, masses, organomegaly - palpation, percussion at McBurney's point, Rovsing's (pain in RLQ with palpation in LLQ) Speculum - external genitalia, vagina, cervix - bleeding from os, tissue present - enlarged cervix (?cervical ectopic) V/E - gentle only, do not want to rupture ectopic - size of uterus, pelvic tenderness - ?hourglass uterus (soft cervix that is disproportionately enlarged compared to the uterus)

HIV physical exam

Physical Exam ¨ General appearance (muscle wasting) - CNS exam (Encephalitis, CNS lymphoma, toxo) - - Skin examination (Kaposi, ulceration) - Oral cavity (thrush, oral hairy leukoplakia) - HEENT- Check for lymphadenopathy - lungs (pneumonia) - Inspect external genitalia for lesions (o Condyloma accuminata, o Condyloma lata (syphilis)) Inspection of vagina & cervix Cultures of vagina (C&S) & cervix (C&S, chlamydia) - screen for STIs... ___/1 PAP smear

post TLH abdo exam

Please describe what you would look for on physical exam. £ Vitals (BP, HR, SaO2, T) £ General appearance Abdominal exam: £ Distension, £ Peritoneal signs £ Location of tenderness £ Bruising £ Masses Incision sites: £ Appearance £ Erythema £ Pus £ Leakage of fluid from port sites £ CVA tenderness Speculum exam: £ Blood £ Pus £ Cuff cellulitis £ Bowel prolapse through vaginal cuff £ Fluid leakage through vaginal cuff Abdo X-RAY CT abdo with contrast CT urogram IVP

OB trauma history

Please outline what you would include in your history? Hx: Age, G, P, LMP (dates?) PregHx to date (US vs LMP) Bleeding, Ctx, FM, ROM, FM ?LOC Wearing seatbelt a. ACCIDENT HISTORY i. Speed of vehicle during accident ii. Airbag deployment iii. Seatbelt use iv. What time did the accident happen Pain: abdo, neck, back PMHx PSurgHx Meds Allergies Smoke EtOH Street drugs FamHx SocHx

what stuff can you ask if a patient comes in post dates for first visit What would you do on exam ?

PmHX POBhx Gyne Hx surg hx Meds allergies Social Hx CTX, LOF, PVB, FM. Exam vitals, height, weight, BMI SFH leopold's (though would do US) FHR cervical exam pregnancy complications Serologies GBS ? Rhesus Ultasounds (position) LOF, PVB, CTX, FM

when are high risk cardiac times in pregnancy

Postpartum Intrapartum At mid-pregnancy (26-28 weeks) when plasma volume expansion & CO demands are at maximum

next pregnancy after anencephaly

Pre-conception high-dose FA and until end of 1st trimester Early ultrasound for NTD Consider referral to MFM

Ergonovine contraindications what can it cause?

Preeclampsia or other high BP heart disease liver/kidney disease protease inhibitors Side effects - Nausea, vomiting, abdominal pain, chest pain, palpitation, severe HTN , Stroke & MI • Note: can cause RPOC

4 absolute contraindications to IUD

Pregnancy Active PID or cervicitis Unexplained vaginal bleeding cervical cancer pelvic TB Known major uterine cavity distortion Post septic abortion • Copper allergy (for copper IUDs) • Breast cancer (for LNG-IUS)

BV possible complications

Pregnancy PPROM, PTB, chorio, endometritis, wound infection Non pregnant wound infection, cuff dehisence, sepsis,

pregnancy complications of hypothyroid

Pregnancy complications: ● PET ● Maternal heart failure ● Placental abruption ● LBW ● FGR ● PTD (< 32 wks 14% vs. 6% if Rx'ed) ● Stillbirth (increased pregnancy loss in T2) ● Fetal distress in labour Fetal and neonatal effects: ● Congenital hypothyroidism ● Congenital cretinism (with iodine deficiency 🡪 growth failure, MR, neuropsychologic deficits) ● Decreased IQ (19% IQ < 85, only 5% of children of mother with normal thyroid glands) ● Delayed development

treat BV in pregnancy vs non-pregnant

Pregnant: metronidazole 500mg PO BID x 7 days Clindamycin 300mg PO BID x 7 days Non pregnant -Metronidazole 2g x 1 possible - metronigazole gel once daily x 5 days - clinda cream once daily x 7 days

vulvar biopsy- control bleeding

Pressure silver nitrate Suture monsel

risks for OHSS

Previous Hx Age < 30 years PCOS high ovarian reserve (basal AFC /AMH) high AFC early in the cycle rapidly rising E2 Use of hCG as opposed to progesterone for luteal phase support Large number of oocytes retrieved (>20)

when to evaluate for primary & secondary amenorrhea

Primary 1) failure to menstruate by age 15 in the presence of normal secondary sexual development 2) failure to menses within five years after breast development if that occurs before age 10. 3) Failure to initiate breast development by age 13 also requires investigation Secondary 1) secondary amenorrhea lasting three months 2) oligomenorrhea involving less than nine cycles a year require investigation

treat HSV pregnancy

Primary acyclovir 400 mg po tid 7-10 days valacyclovir (Valtrex) 1 g po Bid × 7-10 days Recurrent Acyclovir 800mg PO TID x 2 days Valacyclovir 500mg PO BID X 3 days.... OR 1g daily x 5 days Suppressive (at 36w) (treatment can be extended in case of incomplete healing) and receive suppression with - acyclovir 400 mg po tid - valacyclovir 500 mg po bid at 36 weeks until delivery. Women with HIV co-infection may require a longer duration of treatment. Those with severe or disseminated HSV are given IV acyclovir, 5 to 10 mg/kg every 8 hours or 2 to 7 days until clinically improved. This is followed by oral antiviral drugs to complete at least 10 days of total therapy

risk of HSV transmission to fetus with maternal HSV during delivery

Primary infection, defined as HSV confirmed in a person without prior HSV-1 or HSV-2 antibodies, can lead to a 25% to 50% vertical transmission rate if SVD Vaginal delivery during recurrent infection is associated with a <1-5% incidence of neonatal HSV infection. asymptomatic shedding- risk is small (<1%) but not 0 (especially if viral prodrome) Regarding mode of delivery: ◦ If any genital lesion suspicious for HSV is seen at the time of labor, a CD should be performed. SOGC: perform even if prodrome with recurrent due to risk of asymptomatic shedding. (risk is around 1% transmission) An indicated CD for active genital HSV should be performed before membrane rupture or as soon as possible (ideally within 4-6 hours) following rupture of membranes Avoid FBS, scalp electrodes

SOB on magnesium DDX

Pulmonary edema from fluid overload MG toxicity PE cardiogenic shock Aspiration

pregnancy with IUD in place- counselling and management

Rare chance Higher relative risk of ectopic pregnancy if see the strings, remove it. Increased risk of - including spontaneous abortion - septic abortion - preterm delivery - chorio - Endometritis

consequences of TTTS

Recipient fetuses demonstrate: -polyhydramnios - polycythemia - biventricular hypertrophy - diastolic dysfunction, which tends to be progressive without definitive therapy - tricuspid regurgitation, and cardiac failure. Donor twin: oligohydramnois anemia growth restriction pallor (baby & placenta) oliguria oligohydramnios 'stuck twin' contractures pulmonary hypoplasia

Graves/hyperthyroid monitoring pregnancy

Refer to MFM, endocrinology She needs antithyroid medication PTU, methimazole Often with propranolol (takes 1-2 weeks for the anti-thyroid meds to kick in) Neonatology or pediatrics needs to be aware/consult Ultrasound for growth, BPP, fetal heart rate, goiter now and serially Monitor thyroid hormone levels after starting meds every 2-4 weeks Plan for vaginal delivery and C/S only for OB indications Goal: Goal of therapy is to maintain maternal clinical euthyroidism with lowest dose possible, and target free T4 in high normal range

sickle cell management pregnancy

Referral to maternal‐fetal medicine to discuss maternal/fetal risks during pregnancy. • Paternal screening (hemoglobin electrophoresis and/or alpha‐thalassemia genetic screening) for risk assessment of fetal genetic inheritance. • Discontinuation of hydroxyurea and ACE inhibitors prior to conception. • Evaluate for chronic opioid use; counsel accordingly regarding the risk of neonatal abstinence syndrome. • Maternal screening for end‐organ damage and baseline lab assessment including CBC, reticulocyte counts - liver function test - renal function tests - consider EKG, echo type and screen, rubella and varicella immunity screening, ). • Ensure patient has established care with a SCD provider/hematologist for chronic disease care and health maintenance. • Recommend folic acid supplementation (4 mg/day). Consider Hb electrophoresis of partner Serial growth ultrasounds every month; add fetal surveillance if fetal growth restriction develops. • Consider daily aspirin for preeclampsia prevention. • Maternal BP monitoring. • Lab evaluation if concern for crisis (increased pain) including CBC, reticulocyte count, lactate dehydrogenase, haptoglobin, urinalysis, urine culture. • Discuss maternal immunization as SCD causes patients to be functionally asplenic. Patients with SCD should receive the following (in conjunction with SCD provider). All below immunizations are safe in pregnancy. ⚪ Haemophilus influenzae type B (Hib) vaccine: one dose during their lifetime. ⚪ Meningococcal vaccine: two‐dose series at least eight weeks apart initially and revaccination every five years. ⚪ Pneumococcal vaccine: one dose of PCV13 followed by one dose PPSV23 at least eight weeks later. Repeat PPSV23 five years after initial PPSV23. ⚪ Yearly influenza vaccine.

Absolute contra indications to neuraxial analgesia (Williams 26th Ed Table 25-5)

Refractory maternal hypotension Maternal coagulopathy Thrombocytopenia under 70 Prophylactic Low-molecular-weight heparin within 12 hours Untreated maternal bacteremia Skin infection over site of needle placement Increased intracranial pressure caused by a mass lesion

molar contraception

Reliable contraception must be used to avoid pregnancy during follow-up because pregnancy would interfere with the interpretation of hCG results and complicate treatment should persistent disease be diagnosed. Hormonal contraception is safe to prescribe immediately after uterine evacuation and does not increase the risk of persistent disease. Oral contraceptives provide the added benefit of suppressing endogenous luteinizing hormone, which can interfere with the measurement of hCG at low levels. Intrauterine contraceptive devices (IUDs) should be avoided until after normalization of serum hCG levels to reduce the risk of uterine perforation

Assess suspected OHSS

Review cycle related factors: - follicle number/size during stimulation - number of eggs retrieved - E2 levels at peak/trigger - time relation to hCG injection - her age, hx, weight, etc. assess for S:sx - nausea, vomiting, bloating abdo pain, dyspnea, chest pain ... ask about urine output Physical exams: - general inspection (is she in pain, nauseated, SOB) - vital signs - abdo exam for ascites: a) look for distention/measure diameter b) palpation (may feel ovaries) c ) percussion/shifting dullness - listen to lungs (pleural effusions) - check calves (VTE) AVOID INTENSE BIMANUAL (rupture ovaries)

risks of vacuum (baby) When to stop?

Risks of vacuum - subgaleal hemorrhage (almost exclusively with vacuum) - cephalohematoma - bleeding from subgaleal/cephalohematoma may result in higher hyperbili/jaundice - retinal hemorrhages - lower rates of success -Skull fracture may be higher in forceps (not well established) - Intracranial hemorrhage may be higher with vacuum (not well established), especially if <34 week...... vacuum at this GA is not recommended. Vacuum stop - 3 pop offs - 3 pulls over 3 contractions with no progress - 30 mins Forceps Stop- No similar "rules", but should have good descent with each, delivery by 3-4 pulls.

cervical length in twins

SOGC we recommend that cervical length be routinely assessed in dichorionic twin pregnancies at the anatomy scan.... and preferably once again before 24 weeks, with subsequent assessment in women with additional risk factors (e.g., history of preterm birth, uterine over-distention, prior cervical surgery can consider serial surveillence of cervical length

HIV history

Scenario: 33 year G1P0, 12 weeks GA, presents for antenatal care. Hx HIV x 2 years. History ¨ History of pregnancy o LMP, menses regular o U/S for dating o Cramping/bleeding o Hyperemesis ¨ History of HIV o Diagnosis (when) o How transmitted o Caregiver o Most recent viral load and CD4 count o Ever on HAART o Current symptoms o Hix of acute illness § Rash, arthralgias, myalgias, nausea, vomiting o Any AIDS defining illnesses § Cervical ca § Candidal infection § Lymphoma § Coccidiomycosis § Cryptococcosis § CMV (other than spleen, liver, lymph nodes) § HSV ulcers for > 1 month or bronchitis, pneumonitis, esophagitis § Histoplasmosis § Kaposi's sarcoma § Mycobacterium avium complex (MAC) § PCP pneumonia § Salmonella septicemia § Toxoplasmosis of the brain § TB § Wasting syndrome Partner? Tested ? ¨ Past obs hx ¨ Past gyne hx o Pap smear, hx dysplasia o STIs o Menstrual pattern o Previous gyne surgery o Contraception ¨ PMH o TB o Hep B, Hep C ¨ Meds o HAART o Folic acid ¨ Allergies ¨ Smoke ¨ EtOH, drugs ¨ Social history o Risk factors: multiple sexual partners, IV drug use, from an area endemic o Hx blood transfusions, tattoos, body piercing o Partner positive?

maternal blood drop post epidural

Secure her airway breathing and circulation- give 02 Inform anesthesia Do a repetitive vital signs including blood pressure, pulse, O2 sat, RR Give her bolus 500 mL NS Monitor the fetal heart rate closely Give her : Ephedrain or phenylephrine if not responding to fluids Consider an emergency cesarean section there is fetal bradycardia Left lateral position

Causes of sinusoidal pattern

Severe fetal anemia Ruptured vasa previa Severe fetal asphyxia/hypoxia Fetal infection

selective IUGR

Severe fetal growth discordance in monochorionic gestations is variably defined as more than 20% to 25% discrepancy between estimated fetal weights or birth weights of twins in a pregnancy not complicated by TTTS. This definition includes or implies severe intrauterine growth restriction of one twin. The most important determinant of selective (non-TTTS-related) growth discordance in monochorionic twin pregnancies is unequal placental sharing (usually associated with abnormal cord insertion of one or both twins). placentas of monochorionic twin pregnancies complicated by selective growth discordance have a higher frequency of uneven placental sharing or peripheral (marginal or velamentous) cord insertion of at least one twin

growth discordance in dichorionic

Severe growth discordance in dichorionic twins is variably defined as more than 20% or more than 25% discordance between estimated fetal weights or birth weights of twins. Larger weight - smaller weight ....then divide by the larger weight..... and multiply by 100 an international expert consensus defined selective FGR in dichorionic twins as: - an EFW less than the third centile in one twin ...... or ..... at least 2 of the following 3 parameters: EFW < 10th centile in the smaller twin - EFW discordance of ≥ 25% - umbilical artery pulsatility index of the smaller twin > 95th percentile. discordance may be linked to discordant placental characteristics such as placental size, cord insertion type and location, placental implantation and uteroplacental perfusion, and placental parenchymal pathology. In addition, the growth of dichorionic twins may be differentially influenced by nonplacental factors such as : - genetic growth potential - structural or chromosomal fetal anomalies - congenital infection Smaller placenta the smaller twin usually has the peripheral (marginal or velamentous) cord insertion Placental parenchymal lesions (infarcts, fibrin deposition, retroplacental hematoma), when present, are seen predominantly in the territory of the smaller twin.

treat infants to hep B moms

Should receive HBIG & 1st dose of HB vaccine within 12h of birth

What side-effects do you review with the patient prior to prescribing CHC?

Side-effects are common in the first 3 months and are often self-limiting · Changes in bleeding patterns (unscheduled bleeding 30% is first month of use) · Breast tenderness (no evidence w/ RCT, may occur & generally improve w/ time) · Nausea (no evidence w/ RCT, may occur & generally improve w/ time) · Weight gain - NO association · Mood changes - Not shown in placebo controlled trials, some evidence of protection of mood · Sexual function (low libido/vaginal dryness) - decreased sexual fxn = evidence conflicting · Headache - placebo controlled studies do not demonstrate increased incidence · Chloasma

GTN single agent chemo

Single-agent chemotherapy with either:- ActD or MTX achieved comparable and excellent remission rates in both nonmetastatic and low-risk metastatic GTN The most frequent adverse effects are nausea, fatigue, and anemia. alopecia is more common with dactinomycin stomatitis is more common with methotrexate

what is required for delivery of twins?

Skilled OB attendent Able to do breech delivery , internal version, or cesarean higher level center NICU Deliver in the OR IV access Preferably with good analgesia continuous monitoring segment of each cord things in room : ultrasound machine to assess position PPH kit piper forceps

1. What are the potential obstetrical complications (fetal and maternal) associated with opioid use?

Spontaneous abortion .............................................................. ___/1 Withdrawal related symptoms (flu-like symptoms) ........................... ___/1 Malnutrition and dehydration ..................................................... ___/1 Obstetrical or medical complications due to associated drug use or IV drug use (HIV, Hepatitis C) ....................................................... ___/1 Preeclampsia......................................................................... ___/1 Placental abruption ................................................................. ___/1 Fetal growth restriction ............................................................ ___/1 Premature labour and delivery .................................................... ___/1 Premature rupture of membranes ................................................ ___/1 Placental insufficiency ............................................................. ___/1 antepartum hemorrhage ........................................................... ___/1 postpartum hemorrhage ........................................................... ___/1 Overdose and death ................................................................. ___/1

ASRM endometriosis

Stage 1-4, minimal, mild, moderate, severe Based on: · Size of lesions or mass ( <1 cm, 1-3 or >3 cm) · Depth of invasion of peritoneal or ovarian implants · Adhesions (filmy or dense, and location) Extent of cul-de-sac obliteration

Gyne HSV indications for suppressive therapy

Suppressive treatment is suggested for patients who have •at least 6 recurrences per year •significant complications, but fewer than 6 recurrences per year •their quality of life significantly affected •social and sexual dysfunction - Immunocompromised •to lower the risk of transmission to a sexual partner or fetus/neonate (II-B).

indications for prolapse surgery

Symptomatic urogenital prolapse & failure of conservative management. Could include: Sensation of bulge/mass/pressure/vaginal fullness/pain Voiding dysfunction ▪ Urinary retention ▪ Recurrent UTI ▪ Splinting Defecatory dysfunction ▪ Splinting Sexual dysfunction ▪ Altered body-image Symptomatic urogenital prolapse & patient declines conservative management.

risks for uterine rupture

T incision full thickness myomectomy grand Multiparity oxytocin long labor tachysystole ECV trauma Breech

outline management of T1DM in pregnancy

T1 • Dating ultrasound, also nuchal and to monitor growth • Routine antenatal bloodwork, offer IPS • Baseline labs: HbA1c, glucose, BUN, creatinine, AST, ALT, TSH, 24 hour urine • Arrange fundoscopy - for each trimester • Urine culture • Endocrine and MFM, nutrition and nursing (multidisciplinary team coordinated) • Deal with the nausea • Follow q1-2weeks T2 • 18-20 week ultrasound, echo if any abnormality • AFP offered if no IPS • Follow BP • Baseline labs, urine culture • Fundoscopy T3 • Monitor BP • Ultrasounds for growth, fetal wellbeing, dopplers if IUGR • Admit if celestone needed • Baseline labs • Fundoscopy • Schedule induction 38 weeks • C/S consider if >4500grams • Stop long acting insulin day of induction, insulin pump protocol, frequent sugars (q1h) • Requirements of insulin may drop postpartum • Call neonatal to delivery/inform them on admission • Continuous EFM • TSH 6 weeks postpartum • Need 500kCal /day if breastfeeding

outline management of epilepsy throughout pregnancy

T1: ● See her neurologist and regular appointments with them ● Consult MFM ● Antenatal bloodwork, +/- lytes (N/V) ● Dating US ● Anatomic US at 11-13 weeks can identify most severe defects, such as anencephaly ● IPS counselling (especially need of MS-AFP) ● Aggressively treat her N/V ● Avoid seizure provoking stimuli ● Counsel regarding compliance meds ● Drug levels if needed o No need for meds to be adjusted unless seizing more or decreased compliance or seizures very sensitive to levels and levels low. Doesn't improve seizure control. T2: ● Level 2 anatomical scan ● Fetal echocardiogram at 22 wks GA ● MS-AFP as part of serum screening test T3: ● GDM screen ● BP monitoring ● Consider EFW at 32 wks GA Delivery: ● Plan for vaginal delivery & IOL or C/S only for obstetrical indications ● Continue meds in labor ● Some say vitamin K at end for baby especially if enzyme-inducing AEDs (but some say not necessary, not absorbed well & barely crosses placenta), just routine vit K as given to all neonates by injection Postpartum: ● Breastfeeding is OK with medications ● Counsel need to care for baby on floor, bathe baby in very shallow water & supervised, avoid stair climbing while carrying baby ● Avoid using a carrier in front or on their back ● Monitor AED levels through 8th wk PP & adjust doses accordingly to avoid toxicity ● Avoid sleep deprivation (exacerbate seizures)

TAPS

TAPS is a recently described form of chronic twin-to-twin transfusion in monochorionic pregnancies, characterized by the presence of a large intertwin difference in hemoglobin and reticulocyte levels in the absence of oligohydramnios and polyhydramnios TAPS can be diagnosed when: - the middle cerebral artery peak systolic velocity is greater than 1.5 MoM in one fetus (usually an anemic ex-recipient fetus) - is less than 0.8 MoM in the other fetus

options for atypia

TLH, BS.... consider taking ovaries (depending on age ) Other options : do nothing Hormone therapy

Twin Reversed Arterial Perfusion Sequence (A-cardiac Twinning)

TRAP sequence is a severe form of chronic twin-to-twin transfusion in monochorionic twin pregnancies characterized by lack of cardiac development or function, or both, and usually striking malformations of the so-called a-cardiac twin. In this typical constellation of twin and placental anomalies, a twin with circulatory failure (the a-cardiac twin) is perfused in a paradoxical retrograde fashion by a structurally normal "pump" twin through a usually single superficial AA anastomosis—hence the name reversed arterial perfusion. The acardiac twin loses its vascular connections to the placenta, resulting in a bypass of placental villous parenchyma, and depends on the co-twin (donor or pump twin) for all blood supply. The pump twin shunts part of its cardiac output toward the parasitic acardiac co-twin through retrograde flow into its umbilical artery or arteries via the intertwin AA anastomoses, resulting in reversed circulation for the acardiac twin. Because the blood flows in a retrograde fashion through the umbilical artery (a branch of the internal iliac artery) or, in some cases, directly into the abdominal aorta, the lower body of the acardiac twin is supplied preferentially with partially deoxygenated blood. This results in relatively better development of the lower body in most acardiac twins. Two conditions need to be present: - acardiac twin has a structural or functional heart issue... diagnosed early - the placenta must have a specific angioarchitecture, defined by at least one direct AA (and usually also VV) intertwin anastomosis, to support the development of an abnormal (acardiac) twin that would be unable to develop independently.

positve antibody screen, titers and monitoring

The critical titer is the level at which significant fetal anemia could potentially develop. This may be different for each antibody, is determined individually by each laboratory, and usually ranges between 1:8 and 1:32. If mom is affected with a positive antibody screen, do titers q monthly until viable (24w) Then 2 q weeks, as long as below 1:16. .... keep going until delivery at term. If gets above critical value (1:32 ... or 1:8 for Kell), then you determine the FETAL antigen status to see if the FETUS could be affected. Do : - cell free DNA for RhD - amnio for other RBC antigens If negative, then no worries. If antigen positive, MCA doppers q 1-2 weeks starting 18 weeks. If MCA PSV <1.5 MoM, keep repeating q 1 week until 32 week antenatal testing (deliver at term) If MCA PSV > 1.5 MoM, do a cordocentesis to determine hematocrit. - HCT < 30% requires intrauterine transfusion Remember, if a previous pregnancy was affected with alloimmunization, there is NO NEED for titers. Begin monitoring for MCA PSV at 18w.

manage FNAIT

The current preferred approach recommends risk-stratified management with IVIG and prednisone without FBS 75% respond to weekly IVIG, with a 98.7% success rate for preventing ICH For those that do not response, half improve with the addition of high-dose prednisone

maternal CMV testing

The diagnosis of CMV infection is confirmed by viral culture or PCR. The highest concentrations of virus are in plasma, urine, seminal fluid, saliva, and breast milk, with most cultures becoming positive within 72 to 96 hours of onset of infection. PCR methodology permits identification of viral antigen within 24 hour. When a patient's previous immune status is unavailable, a combination of testing for CMV immunoglobulin M (IgM), CMV IgG, and CMV IgG avidity (where available) is recommended. Seroconversion of CMV (IgG) in paired labs 3 to 4 weeks apart is diagnostic of a new acute infection. - rising igG titers suggestive (not diagnostic) (4 fold increase) The presence of CMV immunoglobulin M (IgM) is not helpful for timing the onset of infection because (1) it is present in only 75 to 90 percent of women with acute infection (2) IF it is there (big "IF")... it can remain positive for over one year after an acute infection (3) it can revert from negative to positive in women with CMV reactivation or reinfection with a different strain (4) it can become positive in response to other viral infections, such as Epstein-Barr virus. In the absence of documented recent seroconversion, it is difficult to distinguish between primary infection, reactivation, reinfection, and quiescent disease since all are associated with IgG and IgM antibodies, and rising titers alone are not diagnostic. Determination of IgG avidity is helpful to better assess the acuity of the infection and thus the risk of in utero transmission High anti-CMV IgG avidity suggests that the primary infection occurred more than six months in the past; The combination of low IgG avidity and positive CMV IgM is suggestive of infection within the prior 3-4 months IgG avidity is low in early CMV infections, becoming high 5 to 6 months following primary infection

colposcopy

The key ingredients of colposcopic practice are the examination of the features of the cervical epithelium after application of successive 1) saline 2) 3-5% dilute acetic acid 3) Lugol's iodine solution Thus, the effect of acetic acid depends upon the amount of nuclear proteins and cytokeratins present in the epithelium. When acetic acid is applied to normal squamous epithelium, little coagulation occurs in the superficial cell layer, as this is sparsely nucleated. Though the deeper cells contain more nuclear protein, the acetic acid may not penetrate sufficiently and, hence, the resulting precipitation is not sufficient to obliterate the colour of the underlying stroma. Areas of CIN undergo maximal coagulation due to their higher content of nuclear protein and prevent light from passing through the epithelium. As a result, the subepithelial vessel pattern is obliterated and less easy to see and the epithelium appears white. This reaction is termed acetowhitening, The principle behind the iodine test is that original and newly formed mature squamous metaplastic epithelium is glycogenated, whereas CIN and invasive cancer contain little or no glycogen. Columnar epithelium does not contain glycogen. Immature squamous metaplastic epithelium usually lacks glycogen or, occasionally, may be partially glycogenated. Iodine is glycophilic and hence the application of iodine solution results in uptake of iodine in glycogen-containing epithelium. Therefore, the normal glycogen-containing squamous epithelium stains mahogany brown or black after application of iodine. Columnar epithelium does not take up iodine and remains unstained, but may look slightly discoloured due to a thin film of iodine solution; areas of immature squamous metaplastic epithelium may remain unstained with iodine or may be only partially stained. If there is shedding (or erosion) of superficial and intermediate cell layers associated with inflammatory conditions of the squamous epithelium, these areas do not stain with iodine and remain distinctly colourless in a surrounding black or brown background. Areas of CIN and invasive cancer do not take up iodine (as they lack glycogen) and appear as thick mustard yellow or saffron-coloured areas. Areas with leukoplakia (hyperkeratosis) do not stain with iodine.

signs/symptoms of PPCM

The major clinical finding in peripartum cardiomyopathy is general heart failure. Other findings may include dyspnea, orthopnea, fatigue, dependent edema, nonproductive cough, tachypnea, tachycardia, palpitations, and chest pain. Blood pressure may be normal or increased;in later stages, hypotension is common. Oxygen desaturation may occur. left heart failure (dyspnea, orthopnea, PND, fatigue , weakness and right heart failure (edema, HSM, JVD) some present with arrhytmia, cardiogenic shock

toxoplasmosis fetal infection- rates and severity

The rates were much higher if acute maternal infection was acquired later in pregnancy - 15%, 44%, 71% after maternal acute primary infection at 13, 26, and 37 weeks, respectively. Fetal/neonatal transmission is inversely proportional to time of primary infection. Disease is less common but more severe if maternal infection occurs in the first trimester,

treat fetal toxoplasmosis

The time for transition from the acute infective tachyzoite form of the parasite, which is responsible for tissue destruction in the fetal brain, to the dormant bradyzoite form contained in tissue cysts is clinically important because the cysts are not susceptible to antibiotics. This time (ideally <3 weeks from seroconversion) is considered the therapeutic "window of opportunity" when maternal administration of antibiotics may prevent or reduce fetal neurologic damage the general consensus to use: - spiramycin when therapy is begun in the first trimester (<14 weeks) (1g TID) - pyrimethamine-sulfadiazine when therapy is begun thereafter (≥14 weeks) If AF PCR is positive, start : - sulfadiazine (initial dose of 75 mg/kg, followed by 50 mg/kg every 12 hours with a maximum of 4 g/day) - pyrimethamine (50 mg every 12 hours for two days followed by 50 mg daily) and folinic acid (leucovorin) 10 to 20 mg with each dose of pyrimethamine (decreases bone marrow toxicity) and one week after completion of pyrimethamine therapy [8] . Length of therapy is controversial and has varied for a minimum of 28 days (with ½ dose until term) versus continuing therapy as is until term. Treatment with pyrimethamine and sulfadiazine to prevent fetal infection is contraindicated during the first trimester (pyrimethamine is teratogenic), but at this time, sulfadiazine can be used alone This treatment should be stopped in the last few weeks of pregnancy. Check CBC weekly

cmv transmission

Transmission usually occurs from close contact, with contamination from urine, saliva, blood, semen, and cervical secretions , with the virus being acquired at mucosal sites or by blood-borne , transmission. Biggest risk = kids. Most women practice behaviors that may place them at risk when interacting with children (e.g., kissing on lips, sharing utensils, sharing food, changing diapers, wiping child's nose, handling child's toys) . Compared with no prevention, preventative measures are acceptable to pregnant women including: - avoiding intimate contact with children - frequent handwashing - gloves can impact behavior, and have the potential to reduce CMV in pregnancy. Compared with no prevention, prevention is associated with an 84% decrease in CMV seroconversion during pregnancy, especially in women in contact with children in day care facilities Risk factors are low socioeconomic status, exposure to infective individuals, multiple partners, extremes of age, multiparity, and blood transfusion. Only cellular blood products that contain leukocytes are capable of transmitting. Using leukoreduced blood products, the risk of transmission from a transfusion is approximately 0.2-3% in immunocompetent recipient

beneits of urine drug screening

UDS has several clinical indications. Evidence shows that the addition of urine drug testing to the structured maternal inquiry about substance use can increase the detection of problematic substance use in pregnancy. Identification can facilitate early intervention, including : - treatment of maternal and neonatal withdrawal - counselling - referral for long-term outpatient treatment. Ongoing outpatient monitoring with UDS is also used to advocate on behalf of patients with child protection services and to monitor compliance with prescribed medications (e.g., opioids). Demonstration and documentation of compliance with either abstinence or MMT may be of use for a woman with respect to retaining custody of her child.

cmv ultrasound finding

Ultrasound detects fetal abnormalities in only 8.5% of women with primary CMV infection and in 15% of congenitally CMV-infected fetuses. These findings are growth restriction ventriculomegaly, oligohydramnios, echogenic bowel choroid plexus cyst (unilateral), pleural effusion brain and liver calcification, and hydrops fetalis [24]. Microcephaly, hydrocephaly, and intracranial calcifications are signs of high risk for neonatal sequelae

hematuria investigations

Urinalysis ____/1 Urine C&S ____/1 Cytology if smoking history ____/1 If hematuria: cystoscopy and renal U/S or CT with and without contrast ____/1 PVR ____/1 PUF (PELVIC PAIN and URGENCY/FREQUENCY PATIENT SYMPTOM SCALE) questionnaire ____/1 Voiding diary ____/1

How to do a pudendal block ?

Use a pudendal block trumpet 1% lidocaine For maternal right, insert the right index/middle fingers to feel the ischial spine. Use left hand to operate the trumpet Jab through the sacrispinous needle 1cm medial and posterior Aspirate Inject 3cc.

Tertiary syphilis

Usually becomes clinically manifest after a period of 15 to 30 years of untreated infection. • Without treatment at earlier stages of disease, tertiary syphilis eventually develops in 30% to 40% of infected patients. gummas (chronic granulomas) arotitis (vasa vasorum destruction) neurosyphilis (tabes dorsalis) Argyll Robertson pupil (small pupils that accomodate to convergence, but do not constrict/react to light) Signs: Broad-based axilla Positive Romberg Charcot joints Stroke w/o HTN

Maternal consequences of shoulder dystocia

Vaginal/cervical lacerations infection PPH post op pain complications

mono-mono twins determination

Visualization of intertwined umbilical cords (M-mode with two different heart rates in adjacent loops of cord) is diagnostic of monoamniotic twins. - cord entanglement is not always detected. Another finding is that the intertwin membrane is absent in a monochorionic/monoamniotic twin pregnancy. They also must be same sex.

stool incontinece exam

Vitals Abdo exam Insepect laceration Neuro exam (espec since diabetic) with S2-4 dermatome DRE Assess EAS tone Assess for granulation tissue Dovetail sign- where the anterior perianal folds are absent, indicates a defect in the external anal sphincter. Pain assessment Assess for fistula on pelvirectal exam

physical exam of post partum perineal pain

Vitals, BMI Abdo exam Inspection perineum for dehiscence, Vaginal palpation to make sure repair intact and r/o hematoma or abscess Evaluate for granulation tissue Consider swab for culture Signs of atrophy DRE Prolapse assessment, pain assessment S2-4 dermatomes

WHO groups of functional amenorrhea

WHO group I (hypo hypo)- Normal/low FSH low estrogen WHO group II (eugonad) normal FSH/estrogen WHO group III (hyper-hypo) involves elevated serum FSH levels indicating gonadal failure

pre-op workup for an obese patient

Weight loss - sleep study - ecg - stop smoking - Possible medicne consult - possible anesthesia consult

options for PCOS

Weight loss, exercise, and lifestyle modifications Endometrial protection if not trying to conceive Hirsutism: - COCP for ovarian androgens - hair removal - anti -androgens (spironolactone, flutamine, finasteride, diane-35) Sequential steps • Clomiphene citrate or letrozole • Metformin (may help cause ovulation) • Gonadotropins (FSH + LH) • Ovarian drilling (not used much) • IVF

risks of IOL

What are the risks and contraindications to induction of labor? • Risks o Cesarean section and operative delivery (mainly in primips) o Uterine hyperstimulation and fetal compromise o Risk of uterine rupture (in certain situations) o chorioamnionitis o Failure to achieve labor o Cord prolapse with ARM o Inadvertent delivery of preterm infant (w/o accurate dating) o Water intoxication with prolonged oxytocin PPH (oxytocin fatigue)

define GDM

What is the definition of GDM? - Hyperglycemia with onset or first recognition in pregnancy

pathyphys of GDM

What is the pathophysiology of GDM? - Pregnancy is marked by a relative insulin resistance and hyperinsulinemia - GDM occurs when pancreatic function is not sufficient to overcome the insulin resistance created by changes in diabetogenic hormones during pregnancy - Insulin resistance in pregnancy (greatest in T3) is due to HPL, progesterone, prolactin, placental GH and cortisol - Also increased maternal adipose deposition, decreased exercise, increased caloric intake - ? Type II DM unmasked/discovered in pregnancy

secondary amenorrhea causes (!!!)

What is your differential diagnosis for secondary amenorrhea/categories of disorders or causes? (H-P-O-O) Hypothalamic (hypogonadotropic hypogonadism) Functional hypothalamic Weight loss - exercise, anorexia, stress Chronic illness CNS tumor Craniopharyngeoma (1% ), pituitary adenoma, sarcoid granuloma, tubercular granuloma Infarction/vasculitis/autoimmune infiltration Mumps/encephalitis Radiation/surgery damage Sheehan Chronic disease Eugonadotropic amenorheea PCOS Adult onset CAH Thyroid disease - hyper/hypothyroidism Hyperprolactinemia Hypergonadotropic hypogonadism Gonadal dysgenesis POF - before/after secondary sexual characteristics Autoimmune Fragile X carrier Chemo/rads, Infection

causes of high prolactin

What is your differential diagnosis of an elevated prolactin? 1. Physiologic • Pregnancy • Postpartum or breastfeeding (up to yrs after) 2. Neoplastic process • Pituitary adenoma (found in 10-30% pop'n) • Other PRL releasing tumours 3. Disruption between the hypothalamus and pituitary • Tumour compressing pituitary stalk (macroadenoma) • Craniopharygioma (presents in childhood/teens OR in 50s/60s) • Infiltrative process - sarcoid, TB • Empty sella syndrome • MS 4. Systemic disease • Hypothyroidism (stim by TRH) • Chronic renal failure (↓ clearance) 5. Chest wall stimulation • Herpes zoster • Chest tube • Surgery 6. Medications • Antipsychotics (risperidone) • Antidepressants (MAOI, SSRI, TCAs) • Domperidone • Antihypertensives (atenolol, verapamil) • H2 blockers • Phenothiazines (block DA receptor) • Herbs • Illicit drugs

bowel injury post op management

What is your management now? · Consult general surgery · Monitored bed · Make patient NPO · Consider NG · Start 2 IVs · Correct hypovolemia IV NS · Start broad spectrum Abx · Place foley cather to monitor urine output · Analgesia · Discuss potential surgery IV ABXL Options o Piperacillin/tazobactam if septic o Ceftriazone /Flagyl o Clindamycin/Gentamicin

adnexal mass history pregnancy

What would you do on physical exam? · General appearance · Ht/Wt/BMI · Vitals · Virilization · Thyroid · LNs - supraclavicular/inguinal nodes · Breast · CVS · Resp - effusions · Abdo - masses, ascites · SFH, FHR · Pelvic - pap/swabs · Bimanual - uterus appropriate size, mass palpable (solid/cystic, mobile/fixed, size) · RV

RPL workup

What would you like to order for investigations? Karyotype of both parents +/- karyotypic analysis of products of conception Lupus anticoagulant, anticardiolipin antibodies, anti-β2 glycoprotein I Sonohysterogram or hysterosalpingogram, and/or hysteroscopy, 3D US TSH, Hgb A1C, Prolactin Endometrial biopsy to r/o chronic endometritis Consider a Day 3 FSH, antral follicle count, or AMH to r/o diminished ovarian reserve

neonatal congenital syphilis

When symptomatic postnatally, congenital syphilis is characterized by early and late manifestations. In early congenital syphilis, diagnosed within 2 years of life, common clinical manifestations are - hepatosplenomegaly - osteochondritis or periostitis, - desquamating skin rash - jaundice - anemia, thrombocytopenia - rhinitis Late congenital syphilis Occurs if inadequately treated early syphillis - mulberry molars -notched teeth - saddle nose - saber shins - sensorineual deafness - interstitial keratitis. - Developmental delay - seizures,

why are women at heightened risk of seizure

Why are women potentially at increased risk of seizures in pregnancy? · Stop medication for fear of teratogenicity · Subtherapeutic drug levels o Vomiting o ↓GI absorption due to ↓motility o ↑ renal clearance due to ↑ GFR o Dilution due to expanded plasma volume o ↑ hepatic metabolism o ↓ protein binding · Decreased seizure threshold o Sleep deprivation o Pain in labour o Hormonal changes

fascial dehisence When does it occur? How does it present ? Risk factors? Management?

Wound dehiscence - disruption of fascial layer, 0.3-3% - typically POD 5-8 - most common presenting sign is serosanguinous drainage from wound - can also see evisceration =disruption of all abdominal layers and extrusion of abdominal contents (mortality 15%) - Risk factors: - poor closure (cautery) - increased intra-abdominal pressure (COPD, ileus, bowel obstruction) - hematoma - infection - poor blood supply - radiation - smoking - malnutrition (hypoalbuminemia, low Vit C), - connective tissue diseases - immunosuppression (steroids, chemo) - advanced age - diabetes - incision is explored with a sterile swab or gloved finger to assess for fascial defects - small defect (1-2 cm) in otherwise intact fascia with no associated bowel extrusion may be reapprox with an interrupted fascial suture - complete dehiscence or eviscerations should be closed as soon as they are recognized - bowel can be replaced by using sterile gloves, gently packing it in place with moist lap pads soaked in iodine - IV, initiate broad-spectrum antibiotics - CBC, T&S, electrolytes, Cr - NPO, take to OR, GA - necrotic tissue, clots, and suture material should all be removed - aerobic/anaerobic cultures should be taken - bowel and omentum should be inspected for injury/viability and cleansed with several liters of warm NS - if fascial margins can be located and are not ragged, a Smead-Jones closure with large-bore polypropylene or nylon can be used - subcutaneous tissue and skin are packed open for later delayed closure - if wound edges are ragged or the patient's condition is poor - through-and-through retention suture of No. 2 nylon or polypropylene is used - sutures are placed 2.5 - 3 cm from the skin edges and are passed through all layers - to allow for edema, the sutures are placed 2 cm apart - all sutures are held up before the first one is tied (prevents inclusion of underlying bowel) - skin unopposed between retention sutures approx with interrupted 3-0 polypropylene - leave retention sutures in for 3 wks - NG tube to avoid abdominal distention - continue antibiotics (change based on culture)

PMB history

__age of menarche __age of menopause __HRT __regular cycles prior to menopause -IMB _ paps __ sexually active __ Dyspareunia __ Post coital bleeding __PObs Hx __PMHX __PSHX - __meds __Allergies ( NKDA) __Family Hx

Jarish-Herxheimer

a systemic inflammatory response due to massive release of the treponemal lipopolysaccharides - Occurs in 30-70% of women with early syphilis, 2% neurosyphillis - Common following initiation of treatment within 1-2 hours; resolves by 24-48 hours - Signs/symptoms: fever, headache, pharyngitis, malaise, myalgia, leukocytosis, increased uterine activity, potential preterm labour, NRFHR with decreased fetal movement and potential IUFD - Treatment - symptomatic, 40% hospitalized, 40% will have recurrent variable decelerations which spontaneously resolve without interventions

Maternal rubella

a viral infection characterized by a low-grade fever, headache, sore throat, LAD, malaise, joint pain, myositis, "scarletiniform" rash These prodromal symptoms will usually last 1 to 5 days before the onset of the scarletiniform rash (innumerable small red papules that are widely and diffusely distributed), which may be mildly pruritic. The rash characteristically begins on the face and spreads to the trunk and extremities. It will usually resolve within 3 days in the same order in which it appeared (face first and then body). Polyarthritis and polyarthralgia can develop 1 week after the rash, mostly in adolescent and adult women ( Classically, hands, knees, wrists, and ankles are affected symmetrically for 1 to 4 weeks. Other manifestations, although rare, include tenosynovitis, carpal tunnel syndrome, thrombocytopenia, post-infectious encephalitis, myocarditis, hepatitis, hemolytic anemia, and hemolytic uremic syndrome. It is important to remember that rubella's clinical presentation is non-specific. Other infections can present with a nonvesicular rash, such as parvovirus B19, measles, human herpesviruses (HHV 6 and 7) and enteroviruses. Parvovirus B19 and arbovirus (dengue, Chikungunya, West Nile, and Zika) infections are also associated with rash and joint symptoms. Therefore, consideration should be made to investigate pregnant women for other infections if rubella infection is clinically

Renal disease in pregnancy hx

a. (include PSHx, PMHx, FamHx, Soc.Hx, POB Hx, Allg - at end quickly) b. What age dx c. When had renal transplant, how long ago d. Live donor or cadaveric donor e. Renal status since the surgery i. antirejection episodes, ii. development of hypertension, iii. proteinuria (last 24 hour urine for protein collection), iv. current creatinine (?stable), v. hospitalizations vi. infections - CMV, HSV etc, received vaccines? Pnemococcal, varicella, rubella f. Current medications - therapeutic dose or maintenance dose of antirejection medications, side effects g. Evidence of hypertension - what medications h. Gyne history i. LMP ii. cycle regularity iii. improved since transplant, iv. moliminal symptoms, ?ovulating, v. contraception

If this patient was found to be positive for a mutation that put her at significant risk for ovarian ca and elected to undergo prophylactic bilateral oophorectomy, how would you counsel her?

a. Bilateral oophorectomy is not 100% protective b. Significant risk of peritoneal carcinomatosis (5-7 %) c. Not a "minor surgery", therefore should discuss all of the potential risks d. Review premature menopause and associated risks e. May be more appropriate in patients with increased risk of ovarian ca who have already had breast ca (as a form of adjuvant treatment)

What are the 3 familial cancer syndromes involving ovarian caner that have been identified? (1 point each)

a. Cancer family syndrome (Lynch type II) /1 b. Site-specific ovarian cancer /1 c. Familial breast ovarian cancer /1 BRCA

what should you do if you find microcephaly ?

a. Confirm the GA- based on first trimester crown-rump length or fetal biometry when available. b.A complete maternal medical and surgical history should be obtained, including trauma, bleeding, illness, medication, infectious and teratogenic exposure (irradiation, alcohol, hypoxia, other). c.A detailed 3-generation family history, with documentation of both parental HCs, should be obtained. d.A detailed tertiary care level fetal ultrasound should be obtained to i.Re-evaluate and confirm the previous fetal HC measurements ii.Obtain a detailed fetal anatomic survey to uncover any additional imaging finding that may guide clinical evaluation, with particular attention to the brain e.An appropriate infectious workup should be initiated. In particular congenital CMV infection should be considered, as it is the most common infectious cause of microcephaly. Congenital CMV infection is possible even with previous immunity (non-primary infection) and explains 10% to 14% of prenatally detected microcephaly cases. f.Fetal MRI, when available and if potential findings are likely to alter pregnancy management, should be offered to document any additional cerebral findings when fetal HC measurements are below 4 SD and should be considered if measurements are below 3 SD and other cerebral and/or extracerebral anomalies are present on ultrasound. Ideally, this specialized imaging should be performed at approximately 28-32 weeks gestation (most informative time point with regards to brain structure, although it could be attempted earlier [24-26 weeks]) and should be performed in a centre with expertise in fetal cerebral imaging. g.Whether isolated or in the context of additional structural anomalies, fetal microcephaly requires evaluation by a medical geneticist with expertise in fetal dysmorphology and/or through fetal autopsy, as this finding may warrant additional investigations. These include chromosome analysis through rapid aneuploidy detection, microarray (comparative genomic hybridization), or molecular investigations for single gene disorders (for example, disorders associated with neuronal migration anomalies or cortical malformations). h.For continuing pregnancies, serial ultrasound examinations for surveillance of head growth trajectory, evolving brain pathology, and fetal well-being should be planned.

maternal trauma management workup

a. MATERNAL i. Assess ABC, vital signs 1. Consider nasogastric tube in semiconscious or unconscious patients 2. Maintain oxygen over 95% 3. 2 large bore IVs ii. Expose and examine all body parts iii. Maintain left lateral tilt or manual displacement of uterus iv. Assess uterus 1. Tone, rigidity, tenderness 2. Contractions 3. Fundal height 4. Leopold for fetal presentation 5. Distension or irregular contour 6. Bruises, penetrating wounds v. Vaginal exam 1. If vaginal bleeding ---R/O previa before assessing cervix 2. Sterile speculum a. SROM b. Bleeding 3. Pelvic exam a. Cervical dilatation and effacement b. Cord prolapse c. Fetal presentation b. FETUS i. Fetal tracing, only if mother is stable 2. What imaging or blood work would you order? /7 a. IMAGING i. Plain Xray of cervical spine, chest and pelvis ii. Ultrasound (OBS and pelvic) 1. Placental location 2. Fetal presentation 3. Fetal wellbeing (heart rate and BPP) 4. FAST (intraperitoneal fluid) 5. CT abdo/pelvis b. BLOOD WORK i. CBC ii. Type and screen iii. Kleihauer-Betke Fibrinogen, coagulation panel

maternal/fetal risks of renal disease

a. Maternal i. Worsening renal function if in mod-severe category ii. Proteinuria iii. Hypertenstion iv. Preeclampsia (30% and higher depending on pre-exist Cr and HTN) v. Death - 50% within 15 years of pregnancy vi. Infection - UTI particularly, secondary to immunosuppression vii. GDM if steroid use viii. Graft rejection ix. C-section (only for OB indications, transplant kidney not obstruct labour) x. Hemodynamic changes b. Fetal i. IUGR ii. IUFD / SB iii. PTD (40-60%) iv. PPROM v. Abruption vi. Increased perinatal mortality vii. Congen anomalies with medications - antihypertensives (ACE/ARB if not changed), immunosuppressant meds

1. indications for hospitalization and intermittent fetal and uterine monitoring for 24 hours following a trauma. /8

a. Uterine tenderness b. Significant abdominal pain c. Vaginal bleeding d. Contraction frequency over 1 q10min x 4hrs e. Rupture of membranes f. Atypical or abnormal fetal heart rate g. High risk mechanism of injury h. Serum fibrinogen <200mg/dL

reasons for prolonged monitoring/admission after trauma

a. Uterine tenderness b. Significant abdominal pain c. Vaginal bleeding d. Contraction frequency over 1 q10min x 4hrs e. Rupture of membranes f. Atypical or abnormal fetal heart rate g. High risk mechanism of injury h. Serum fibrinogen <200mg/dL

risk of PPH tissue

accessory lobe accreta , increta, percreta (risks for accreta - previous CS, infection, uterine surgery)

acquired vs inherited risks of PPH bleeding disorder

acquired: -preeclampsia and HTN - gestational thrombocytopenia - DIC Inherited - von willebrand - hemophilia - Platelet disorders - Marfan

DDX for sickle cell chest pain

acute chest syndrome PE cardiac causes Pneumonia Covid/other viral VTE

Maternal complications of sickle cell

acute chest syndrome infection (pneumonia, UTI) Pyelo, sepsis hypoxia Pulmonary HTN cardiac issues VTE HTN with complications (eclampsia, stroke, seizure)

exercise recommendations pregnancy

add

pelvic abscess management

admit IV antibiotics : Piptazo , +/- vanco Clinda/Gent , possibly amp Ceftriaxone/flafyl IR guided drainage- send that for culture and sensitivity

risks for SUI

age multiparity obesity smoking menopause chronic cough heavy lifting b

adolescent heavy menstrual bleeding Hx

age of menarche cycles regular, irregular heavy (how much ? ), clots? color ? how long are cycles? IMB ? LMP? dysmenorrhea? Symptoms of anemia ? (fatigue, palpitations, dyspnea with exertion, weakness, pale ? ) PMHX, meds, PsHx, fam Hx, allergies, HEADS - home - education , eating - activities - drugs - sex /safety , safety

OHSS

almost exclusively associated with exogenous gonadotropin stimulation and is ......only rarely observed after clomiphene citrate treatment or spontaneous ovulation the central feature of clinically significant OHSS that is it is a systemic condition which is probably VEGF mediated, causing development of vascular hyperpermeability, then LOSS of ALBUMIN..... and the resulting shift of fluids from the intravascular space, into the third space (peritoneal and thoracic cavities) mediated by molecules such as VEGF (stimulated by hCG)... and others such as IGF-1, IL-6, angiotensin II, There is also hemoconcentration which increases risk of VTE

containdications to emergency contraception

already pregnant (not an abortifact) anaphylaxis Caution for COCP in women with contraindications to estrogen - smoker, HTN, thrombophilia, stroke, migraine with aura etc Copper contraindications

treat syphilis

always pen G If allergic (even anaphylaxis), do desensitization .... usually orally in a hospital setting. Primary, secondary, or early latent (1 year)- 1 dose Unknown latent, late latent or tertiary = (3 doses q weekly) neurosyphillis= IV for 2 weeks straight

diagnose fetal syphilis

amnio for PCR US can be suggestive

diagnose fetal toxo

amniotic fluid PCR Done after 15 weeks should be offered no less than 4 weeks after suspected acute maternal infection to lower the occurrence of false-negative results (II-2D).

what services would you consult if heavy bleeding ?

anesthetist, a second gynaecologist, a general surgeon, a vascular surgeon, a critical care specialist, a hematologist, and experienced nursing staff, should be considered when appropriate and if available.

fetal complications of sickle cell

anomaly preterm birth abruption stillbirth

diagnose varicella

anti-VZV IgM antibody. infection may be confirmed by NAAT of vesicular fluid or by Tzanck smear of vesicle base

when in the cycle to start COCP ?

any time If you start at menses, no backup contraception is needed can start immediately after a miscarriage or abortion

what vessels at risk of umbilical entry

aorta the left and right common iliacs

What things do you want to do on exam before assisted delivery ?

assess for fetal position, if the head is extended, any caput or molding. What station. Adequate assesment of the pelvis. Cervical dilation If the head is flexed, deflexed

Urodynamics

assesses how well the bladder and urethra are storing and releasing urine 1) Filling Cystometry 2) Uroflowmetry 3) PVR 4) Pressure flow study 5) Urethral pressure profile 6)Electromyography

what is SLE?

autoimmune disease characterized by an abnormal immune response in which auto (self) antibodies cause damage to various organ systems, including: - skin - joints - kidneys - lungs - liver nervous system

Methotrexate counselling

avoid pregnancy 12 weeks · Stomatitis · Gastritis (N/V/D) - common · Bone marrow suppression · Alopecia · Pleuritis · Elevated liver enzymes · Dermatitis Council on reasons to go to the ER

chlamydia treatment options

azithromycin 1g x 1 Amoxicillin 500mg PO TID x a week Remember, in pregnancy, TOC in 2-4 weeks

how can you evaluate for ovulation

basal body temp (highest fertility is in week before the mid cycle rise) .... not really accurate/recommended LH kits - surge 1-2 days before ovulation progesterone levels (1 week before onsert of menses) U/S (# of follicles)

lab tests in SLE Manage a pregnancy with SLE

baseline labs of disease activity - ANA - anti dsDNA (correlates with disease) - anti Ro, anti LA - anti phospholipid antibodies (lupus anticoagulant anti beta 2 glycoprotein igG/igM anti cardiolipin IgG/IgM CBD baseline liver function kidney function electrolytes monitor BP all pregnancy stuff Will need multidisciplicary referral - rheumatology - thrombosis (anticoagulation) - MFM, NICU - anesthesia fetal echo scans for growth restriction monitor BP closely

when to do urodynamics

before surgery for stress incontinence refractory urge incontinence incontinence with prior mesh procedures recurrent/complicated UTI's Advanced prolapse The indications for urodynamic testing are controversial. It is generally accepted that UDS are not needed prior to conservative management of UI by such means as a pessary, biofeedback, bladder drills or anticholinergics. Suggested indications include the following: -Diagnosis remains uncertain after initial history and exam. -Symptoms do not correlate with physical exam -Fails to respond to treatment -Research -Surgical intervention is planned - prior surgery - maybe severe prolapse

risk factors for UTI

being female spermicide post menopausal Previous UTI's Sexually active, frequent intercourse New partner Medical conditions - diabetes - sickle cell - voiding dysfunction (inability to empty bladder) - bladder surgery - fistula - immobility - poor hygiene

in what 2 conditions may FMH be falsely positive? false positive kleihauer

beta-thalassemia pregnancies near term

ways to reduce PPH

bimanual massage empty bladder cord traction- maybe uterine packing bakri jada device UAE surgical techniques -O'leary internal iliac ligation b lynch and variations cho stitch stepwise devascularization hyst

endmetrial thickness on HT

bleeding- non bleeding - 8mm Review how people take it, ensure they take it properly.

HIV transmission ways

blood, semen, vaginal fluid, breast milk (hepatitis doesn't have this ) vertical transmission 20% vertical transmission before 36w 50% near delivery 30% intrapartun breast feeding risk can be 20% If treated for 6+ weeks, very low risk, < 1%

hepatitis mode of delivey Hep B hep C

both usual ob indications Avoid scalp clip, episiotomy, instrumental delivery

Management of septic shock

broad spectrum IV ABX IV resuscitation- fluids Vasopressors Source control b) Management: Stabilize patient a. Call rapid response team (if available) b. Consider transferring to an acute care environment (ex.ICU, OR, one-on-one nursing) c. Fluid resuscitation IV bolus crystalloid (30 cc/kg) d. Consult Anesthesiology (central line, arterial line, arterial blood gas) e. Bloodwork (CBC, electrolytes, BUN, CR, coagulation profile, CRP, serum lactate, blood cultures × 2 (anaerobe and aerobe, 2 sites) 2. Source control - immediate laparotomy and surgical drainage 3. Consider consultation from general surgery 4. Arrange postoperative care in ICU/ICU consultation

what ancillary meds to give in hemorrhagic shock

broad spectrum antibiotics (gut ischemia causes bacterial overgrowth and sepsis) Antacids or H2 blocker for HI prophylaxis from stress ulcers

urinary incontinence hx

calgary cambridge fluid intake (caffeine, tea, how much fluid, smoking, alcohol) Ob hx Gyne Hx (menopause, GU symptoms, dyspareunia) Description of urinary symptoms (0.5 pt for each) ▪ Frequency ▪ Urgency +/- urge incontinence ▪ Stress incontinence (coughing, sneezing, laughing, walking) ▪ Constant leakage ▪ Coital incontinence ▪ Amount loss ▪ Frequency of incontinence / number of pads changed daily ▪ Duration of symptoms ▪ Dysuria ▪ Hematuria ▪ Nocturia ▪ Obstructive symptoms: incomplete voiding, hesitancy, weak stream, straining , double voiding ▪ Post-void dribbling ▪ Digitation ▪ UTIs Prolapse history Bulge, pressure constipation? digitation/splinting ? Incontinence? pain?

cardiac disease in labor monitoring

careful fluid management, avoid hyper and hypovolemia blood work Left lateral Epidural to avoid pain (but watch for hypotension) exams for fluid overload, peripheral edema Consider ART line Condiser cardiac monitoring Consider invasive cardiac monitoring

TTTS

chronic fetofetal blood transfusion from one twin (donor) to the other (recipient) through placental vascular communications. This unbalanced shift of blood volume results in hemodynamic imbalance: Larger twin --> Polycythemia & Polyhydramnios. Smaller twin --> Anemia and Oligohydramnios. (so-called twin oligohydramnios-polyhydramnios sequence). Normally, a paired artery and vein supplying and draining a placental cotyledon .... here, this does NOT develop. Instead, an arteriovenous (AV) anastomosis occurs on the placental surface, whereby a: - single unpaired artery carrying blood from the donor twin to a placental cotyledon connects directly into a single unpaired vein carrying blood from that cotyledon back to the recipient twin An intuitive, albeit simplistic, model of TTTS proposes that the primary event is flow imbalance from donor to recipient across unbalanced unidirectional AV anastomoses. If this flow imbalance is significant and not fully compensated by bidirectional AA anastomoses, the donor becomes hypovolemic and anemic, whereas the recipient develops polycythemia and hypervolemia. These volume changes are believed to induce modulation of a variety of hormonal and biochemical regulators in both twins. The renin-angiotensin system is upregulated in the donor twin and downregulated in the recipient twin. addition, concentrations of atrial natriuretic peptide brain natriuretic peptide endothelin-1 are higher in the amniotic fluid of recipient twins compared with donor twins

types of uterine conservation in accreta

clamp the cord with an absorbable suture 1) One step conservation - resecting the placenta along with the invaded myometrium in bloc. The steps of this procedure include ligation of the newly formed blood vessels between the uterus and the surrounding structures, followed by a hysterotomy and removal of the placenta with the affected area until reaching healthy tissue, hemostasis and finally uterine reconstruction in two layers 2) Triple P procedure uterine preserving technique is a three-step conservative surgery for women with PAS, and it requires the presence of an interventional radiologist. It consists of - perioperative location of the upper border of the placenta - pelvic devascularization by a pre-placed pelvic arterial balloon catheter in the anterior division of the internal iliac artery after delivery of the fetus in attempt to reduce the blood supply to the placenta - and in bloc resection of the placental and myometrial tissues involved. - Finally, the myometrial defect is reconstructed 3) Uterine devascularization can be achieved through several techniques such as iliac artery embolization, bilateral uterine or hypogastric iliac ligation and balloon occlusion in an attempt to prevent secondary postpartum hemorrhage and possibly accelerate placental resolution 4) Consider hystreoscopic resection, guided by laparoscopy or ultrasound

Hyrops

collection of fluid in 2 or more cavities - pleural - cardiac - abdominal Can also be, 1 cavity plus general swelling Immune hydrops: mom's immune system attacks/destroys baby's blood cells non immune (90%) - caused by a fetal medical condition

follow up after LEEP

colpo , pap, ECC at 6 months post treatment--all negative colpo, pap and ECC , HPV typing 12 months post treatment-- if all negative --can DC to routine screening every 3 yrs does this change if HPV positive? --DC to annual screening

GTD

condition in which trophoblastic tissue overtakes the pregnancy and propagates throughout the uterine cavity 4 categories: 1) Mole (complete vs partial) 2) gestational trophoblastic neoplasia (GTN)- (malignant). a) choriocarcinoma b) invasive mole c) PSTT d) ETT 3) Placental site nodule (benign) 4) exaggerated placental site tumour (benign) GTN can be preceded by a molar or non-molar pregnancy

acute chest

condition with sickle cell due to vaso-occlusion in the pulmonary vasculature, and - chest pain - hypoxemia - infection (so patient has a temp) - chest infiltrates - tachypnea, wheeze, cough management includes: - if hypoxic, then aggressive pulmonary hygiene to keep lungs clear and maintain sats (ie, oxygen, bronchodilators ) - consider blood transfusion for mild desats, with exchange transfusion if it progresses - mechanical ventillation may be necessary Also, usual management - adequate hydration - analgesia - antibiotics

benefits of endo surgery

confirm diagnosis (and obtain tissue specimen) Improve pain restore normal anatomy • Improve fertility reduce risk of cancers from endo

microadenoma

consult endocrine If asymptomatic, If sympatomatic (amenorrhea, galactorra) then treat with dopamine agonists. · Treat with dopamine agonist therapy i. Bromocriptine 2.5mg QHS start then increase to TID as tolerated ii. Cabergoline 0.25mg 2x/wk · Recheck PRL levels 1 mth after steady dose reached

how can hep B be transmitted

contact with blood, semen, or other bodily fluids - sex - sharing needles (TATTOO's!!) - direct contact with sores - vertical transmission

postpartum management of HIV

continue anti-retrovirals Baby will require triple therapy do not breastfeed (if undetectable, the risk is ~1%... which isn't zero )

name benefits of the Mirena

contraception - reduce menstrual volume - reduce endometrial hyperplasia/cancer - menstrual suppression, so treats dysmenorrhea - may prevent ovulation, so may lower risk of ovarian cancer

fistula exam vesticovaginal and rectovaginal

cystoscopy Methylene blue tampon test Rectovaginal • Methylene blue • Pt in Trendelenberg: Air in rectum through foley catheter, water/soap in vagina • Colposcopy • Anoscopy, proctoscopy • Fistulography - dye in vagina/rectum ○ Not as good as barium swallow • Evaluate the anal sphincter! - endoanal ultrasound, MRI

methotrexate follow up

day 0, 4, 7 , weekly (till 0)

neonatal consequences of varicella

death developmental delay low iq/learning disabilities - seizures - limb abnormalities Occular findings- cataracts, blindness cutaneous rash Disseminated varicella is severe - disseminated lesions - pneumonia - encephalitis - meningitis - death n the absence of timely antiviral therapy, up to 30% of infected infants die of complications of neonatal varicella. Give baby VZIG and IV acycloivir

early concerns of pprom

death is sky high Pulmonary hypoplasia, RDS, IVH, NEC, mental disability potter sequence- limb contractures, low set ears, abnormal face,

Surgical management of torsion

detort Assess the ovary- though unless it is grossly necrotic, would just detort Consider cystectomy Consider oophoropexy Examine the opposite side

fecal incontinence exam

dietary modification- high fiber diet wear briefs Pelvic floor physio , strengthening exercises Ultrasound for evaluation Anal mamometry Refer to urogyne or gen surg

hypothyroidism in pregnancy

dry skin, weakness, weight gain, carpal tunnel, goiter, hair loss, constipation,

fetal and neonatal alloimmune thrombocytopenia aka FNAIT

due to platelet destruction from maternal antibodies against fetal human platelet antigens (HPA) inherited from the father. It is also called neonatal Alloimmune thrombocytopenia (NAIT) alloimmune thrombocytopenia (AIT), or fetal maternal alloimmune thrombocytopenia (FMAIT). FNAIT is similar to RBC Rh disease: • Like red blood cells, platelets have specific surface proteins called antigens. • Fetus inherits paternal antigens that the mother lacks (platelet antigen incompatibility). • Mother develops antibodies (becomes sensitized) to fetal platelet antigens during pregnancy. • Maternal IgG anti-platelet antibodies cross the placenta and coat fetal platelets resulting in sequestration and destruction of platelets in the fetal reticuloendothelial system. FNAIT differs from Rh disease: • Antiplatelet IgG production can occur in first pregnancy. • Firstborn children are often affected since anti-platelet IgG production can occur in a first pregnancy; nulliparous women account for 20-60% of cases. • Maternal antibody titers do not predict pregnancy outcome The natural history of FNAIT ranges from mild asymptomatic fetal/neonatal thrombocytopenia to severe thrombocytopenia leading to intracranial hemorrhage with potentially severe perinatal morbidity and mortality. • Ninety percent affected neonates having diffuse petechiae. • Ten percent to 30% ICH • Approximately 75% occur antenatally, as early as 20 weeks.

female infertility hx

duration of infertility Characteristics of intercourse (frequency, function) - spermicides Previous evals/treatment Menstrual hx -menarche age cycle length cycle characteristics -dysmenorrhea moliminia symptoms hx of pregnancy : ( GPTAL, pregnancy outcomes/complications, TTC, fertility treatments) Hx contraception Past gyne hx - PID/infections - paps - endo dys's questions (dysmenorrhea, dysparunia, dischezia, dysuria) general - thyroid disease galactorrhea - hirsituism Pmhx Pshx allergies social (drugs, tobacco, MJ, occupational exposures) Fam hx - develpmental delay, birth defects, reproductive issues like infertility or early menopause

conseuquences of GBS Early vs late

early = <7 days Late = 7+ meningitis pneumonia bacteremia

post op care of obese

early mobility incentive spirometry DVT prophylaxis intra-op, consider post op compression stockings Try NSAIDs, low opioids

ultrasound findings of OHSS

enlarged ovaries. Early intraperitoneal fluid accumulation can typically be visualized only through vaginal ultrasound (often hidden by ovaries on abdo US)

causes of growth restriction

etiologies that may be - placental - maternal - fetal in origin. Although the most growth‐restricted fetuses are constitutionally small, this should be a diagnosis of exclusion and an underlying etiology should be sought. When a fetus is identified to have EFW below the 10th percentile, - Constitutional (up to 70% of cases) Maternal disease affecting placental perfusion • Chronic hypertension • Other cardiovascular disease • Renal disease • Autoimmune disease • Pregestational diabetes with end‐organ involvement • Chronic anemia (sickle cell anemia) • Maternal cyanotic cardiac disease Preeclampsia/gestational hypertension Prior pregnancy with FGR or stillbirth Substance abuse • Cocaine, methamphetamine (vasoactive substances) • Heroin, other opiates/opioids Cigarette smoking Alcohol Teratogens (methotrexate, cyclophosphamide, other antineoplastic medications, immunosuppressants, maternal phenylketonuria) Severe dietary and/or nutritional restriction Placental: Placental hematoma or chronic abruption Chorioangioma of placenta Circumvallate placenta Velamentous umbilical cord insertion Single umbilical artery (controversial, some studies suggest) Fetal: Fetal genetic abnormalities (e.g., trisomy 18, other aneuploidies and syndromes) Fetal structural abnormalities (gastroschisis, hydrops, etc.) Fetal congenital infection (prevalence and risk vary) • Cytomegalovirus • Toxoplasmosis • Parvovirus • Zika • Rubella • Varicella/herpes virus • Malaria Complicated multiple gestation • Twin discordance • Selective FGR • Monochorionic twin complications: • Twin-twin transfusion sequence • Twin‐anemia‐polycythemia sequence

when to follow up of pessary?

every 2-4 weeks remove it clean it check for erosions

What elements of physical exam and investigations are important before torsion ?

exam: Vital signs BMI Abdominal exam for surgical scars Investigations : bHCG vitals labs (hb, liver/kidney funxtion, etc) CBC, ABO PT/INR ultrasound

Parvovirus testing in mom

f IgG positive + IgM negative, the woman is immune and should be reassured that she will not develop infection and that the virus will not adversely affect her pregnancy . (II-2A) - If both IgG and IgM are negative (and the incubation period has passed), the woman is not immune and has not developed the infection. She should be advised to minimize exposure at work and at home. Absence from work should be considered on a case-by-case basis . (II-2C)NOTE: IgM usually appears up to 14 days... and persists ~4 months. IgG positive and IgM positive Maternal parvovirus B19 IgM antibodies can be detected approximately 3-10 days after exposure and typically persist as long as four months. proceed to evaluation

risks of forceps neonatal

facial lacs facial nerve palsy (does not happen with vacuum) corneal abraisions occular trauma Neonatal skul fracture is more common Forceps has lowest indicence of neurologic complications, then vacuum, then cesarean Skull fracture is similar forceps and vacuum

SOGC target glucose

fasting- 5.3 Postprandial 1 hour- 7.8 2 hour- 6.7

factors that increase success of IOL

favorable cervix Multipartiy Normal BMI young maternal age

risks for SLE

female sex reproductive age family hx races (african, asian)

complications of ECV

fetal bradycardia rhesus sensitization abruption PPROM preterm labor AFE

risks of diabetes

fetal: -LGA- - shoulder dystocia, injury (brachial plexus) - increased operative delvery operative delivery - poly - PTB - Inpaired pulmonary maturity, RDS - polycythemia... causing hyperbil and jaundice - hypoglycemia - hypocalcemia - fetal cardiomyopathy (usually resolves) - death - increases the risk of c/s - preeclampsia

symptoms of hepatitis Signs of hepatitis

fever fatigue loss of appetite nausea vomiting abdominal pain joint pain signs dark urine, light-colored stools, jaundice.

manage a subsequent pregnancy with hx of preterm birth

follow closely urine culture BV, chlamydia, gonorrhea Consider serial ultrasound, 16 weeks on (q 2 weeks) No indication for bed rest watch closely, consider admission, steroids

Follow up after torsion

follow up ultrasound after Consider COCP's (cyst prevention) Possible cystectomy

Give 2 examples of heritable causes POF due to a single gene mutation that may lead to secondary amenorrhea?

fragile X galactosemia

US techniques to improce image quality in obesity

full bladder (abdo) Scan transvaginlly Below the panus... or sit up and above the panus

maternal trauma history

full medical history Current pregnancy history Dating, how it was dated Serologies Blood type + rhesus ultrasounds Details of the trauma Contractions, LOF, PVB, FM

post op cesaran chest pain management

full vitals (BP, O2, HR, temp) ECG CXR Trops , CK nT pro BNP MAYBE cardic echo Leg ultrasound Consider CT PE Preeclampsia workup CBC, lytes, BUN/Creat, AST/ALT, uric acid, urine PCR

consequences of PPH

further interventions, iron deficiency anemia, pituitary infarction (Sheehan's syndrome) associated poor lactation, exposure to blood products, coagulopathy, organ damage with associated hypotension and shock.

SOGC silly recommendation on when to induce What are benefits ?

generally, 41+3 Benefits: - decrease perinatal mortality - decrease CS - reduced meconium aspiration - less shoulders, CPD , - less hypertensive disorders

men with oliogozoospermia history

genetic counseling referral to urology- TESA, ultrasound genetic testing for CF (obstructive) - hormonal (LH, FSH, test) - karyotype - testing for Y chromosome microdeletion Test for - auto Antibodies - semen C&S - semen biochemistry

etiology of microcephaly

genetic in 31%, (ie, PKU) perinatal brain injuries in 27% (including antenatal infection and maternal exposure to teratogens), and unknown in 41% Non-infectious causes of microcephaly include maternal exposure to heavy metals or toxic chemicals, such as arsenic or mercury; alcohol; radiation; smoking; and pre- and perinatal injuries to the developing brain (hypoxia-ischemia, trauma).

council after stillbirth

grief counseling MFM referral try to prevent modifiable risk factors May be higher risk of recurrence in next pregnancy guideline mentions screen for PAPP-a and uterine artery- but very soft

causes of hypothyroid in pregnancy

hashimoto's mostly in developed world Iodine deficiency worldwide thyroidectomy radioactive iodine treatment thyroid cancer

how long to follow GTN

he serum hCG is monitored weekly for the first 4 to 6 weeks and then monthly for a minimum 1 year in low risk monthly for a minumum of 2 years Pregnancy should be avoided with the use of reliable contraception, including hormonal methods and an intrauterine device, during the surveillance period. IUD only once <5

risks for expulsion of Mirena

heavy menstrual bleeding fibroids mullerian uterine anomalies Previous expulsion Family Hx of expulsion

female infertility physical exam

height, weight, BMI, general inspection Look at androgen access, skin changes Breast characteistics thyroid exam for enlargement/nodules Pelvix exam - uterus size, shape, mobility - tenderness, nodules - adnexal masses Cervical exam (secretions)

Incontinence exam (physical exam and workup)

height, weight, BMI, vitals Vaginal exam. Speculum cough test, suping or standing, consider Q-tip Testing: Urinarlysis + culture · Uroflowmetry (need at least 150cc for valid test) o Peak flow rte 19 ml/s (normal >15ml/s) o VV 400cc (what is normal capacity? 400-600cc) · PVR: 10cc (normal) · Urodynamics (state reason for UDS - to clarify diagnosis) · Total /5

meds that worsten asthma

hemabate labetalol

lab values in OHSS what would you order??

high hCG / estrogen low albumin high HCT High WBC High Platelets high hCT hyponatremia hyperkalemia CBC, ABO, PT, PTT, liver function, kidney function Order: CXR ECG ultrasound abdo/pelvis

treat lichen sclerosus

high potency steroid (ie, clobetasol ointment) - - nightly x 2 weeks - eod x 2-4 weeks - 2x a week ongoing tacrolimus - calcineuron inhibitor Prevents cancer (dVIN, progress to SCC) Ancillary treatment: PMB: estrogen vulvar hygiene Phototherapy Pain management: TCA or gabapentin

what increases risk of hep b vertical transmission

high viral load e antigen Untreated TPTL, or maternal fetal hemorrage

risks of turner syndrome for pregnancy

higher risk of miscarriage Cardiac complications (depending on) BP complications (depending on renal function) Higher rates of CS

investigate UTI

history Physical exam - look at the anatomy, prolapse, atrophy, irritation, cervicitis/vaginitis urinalysis urine culture Consider imaging - ultrasound - cysto or IV pyelogram

what can cause a sickle cell criis

hypoxia dehydration infection stress surgeries pregnancy exertion

name 5 procedures where you can kink the uteter

hysterectomy (open, laparoscopic, vaginal BSO Anterior repair colpoclesis

prognostic factors in endometrial CA

i. Age (younger is better) ii. Histologic type iii. Histologic grade iv. Myometrial invasion v. LVSI vi. Cervical extension vii. Adnexal involvement viii. Peritoneal cytology? ix. Lymph nodes x. Intraperitoneal tumour xi. Tumour size < 2 cm is best xii. Hormone receptor status xiii. DNA ploidy and proliferative index xiv. Genetic and molecular markers - Kras, HER2 neu, p53 Low risk- G1, G2 no myoinvasion - low grade, no nodes High risk = grade 3, pappilary/serous/clear cell, with LVSI,

when to start insulin

if diet and exercise fails for 1-2 weeks Very poorly controlled sugars especially if early

assss bladder integrity

if open, can feel the foley bulb Cysto Retrofill the bladder methylene blue

how to manage varicella exposure? non pregnant vs pregnant

if vaccine history is not known, give the vaccine. If pregnant or immunocompromised, give VZIG

when to treat Hep B

if viral load is high >200,000 Especially if e-antigen positve Start 24-28 weeks - treat 3 months post partum Patients who are co‐infected with human immunodeficiency virus (HIV) must have triple‐agent highly active antiretroviral therapy which can include tenofovir or lamivudine to treat both HIV and HBV

what causes worsening cardiac disease in pregnancy

increase in blood volume causes an increase in cardiac output Increased HR can precipitate arrhythmia physiologic anemia can cause ischemia

maternal risks of operative vaginal delivery

increased degree of perineal tears, OASIS Stool/flatal incontinence Cervical lacerations Post op pain fistulas Prolapse Psychological impact

Risks of late PPH

infection (endometritis) retained tissue bleeding disorder

What are causes of acquired POF that may lead to secondary amenorrhea?

infection (mumps, TB) Pituitary infarcts side effects of malignancy (chemotherapy, radiation)

risks of LEEP

infection, bleeding, cervical stenosis, persistent disease, and possibly risk for preterm delivery

AMA risks

infertility miscarriage aneuploidy Anomalies HTN preeclampsia GDM dystocia post dates growth restriction stillbirth

recommended vaccines in pregnancy

influenza tDAP (25-32 weeks) covid

prerequestites for operative delivery

informed consent experienced provider fully dilated position is certain head is engaged adequate analgesia bladder empty Presence of NICU

Penicillin desensitization

initially test the patient for the allergy.... most will NOT have the allergy. If they do, then desensitization is done, orally in a hospital setting a. If unable to desensitize - use erythromycin but it will not cross the placenta so the baby will have to be treated

investigate post op surgery fever

inspection, physical exam Complete physical exam Abdomen speculum exam- look at vault - consider palpate to ensure in tact imaging: CT contrast (preferable) or ultrasound labs CBC lactate ABO electrolytes PT/INR, Liver function, kidney function Pan culture: blood culture, urine culture, genital swabs Procalcitonin

DDX for UTI

interstitial cystitis PID OAB vaginitis cervicitis

what to do if the mom does get symptoms of varicella despite prophylaxis

isolate, admit.... IV acyclovir

General immediate pre-winRHO counseling

it is a blood product, pooled product Possible side effects - fever, rash- if so, stop and give tylenol - very low risk of infection (bacterial, hiv, hepititis)

what do you tell a patient on finasteride?

it is a teratogen, so reliable contraception is needed

what is plan B? How can you take it ?

it is levonogestrel- a progestin Single tablet

sickle cell in labor and delivery

keep well hydrated minimize pain (early epidural) continuous monitoring monitor vitals closely maintain high O2 Ensure crossmatch Postpartum VTE

evaluate for urteteric injury

labs: CBC, BUN/creat, lytes ultrasound- shows hydro CT urogram retrograde pyelogram

failed uterine inversion surgeries

laparotomy Huntington procedure - babcocks or allises walking along the round ligament or walking sutures moving from lateral to central in and attempt to turn the uterus in side right Haultain procedure Hyst

dysgerminoma surgery

laparotomy- USO, possible staging, (biopsy abnormal tissues) Midline laprotomy, assemble bookwalter Pelvic washings frozen section

laparoscopic management in a pregnant patient

left lateral tilt FHR auscultation before/after no uterine manipulator Consider moving ports up, depending on GA Keep pressure low, 15 mmHg post op: - avoid NSAIDs - auscultate FHR - early ambulation

tolac benefits

less - bleeding - infection - VTE - damage to nerves, bowel, bladder - less post op pain - shorter hospital stay - less risk in future pregnancies

benefits of MIS approach

less infection less bleeding less post op pain less VTE Less hospital time cosmetic

PAS surgery itself

lithotomy with stirrups urology consult - possible ureteric stents - possible 3 way foley Consider midline laparotomy vs IV antibiotics TXA consider intra op ultrasound classic CS with fundal incision

adult varicella symptoms

low grade viral symptoms - fever, headache, runny nose, sore throat, LAD, malaise, loss of appetite.

retained placenta management

manage PPH ABC, IV, help Go to OR foley Analgesia (spinal, epidural... or general) try umbilical vein oxytocin attempt manual removal - if focal accreta - curette remaining placenta placental site and oversew placental bed - if bleeding not controlled, wedge resection of myometrium

rpoc options

manual removal curettage hysteroscopy open

risks for anomalies

maternal age previous anomalies family hx of anomalies infections medical conditions maternal age nutritional deficiency mediations

cystic fibrosis- who to test

maternal symptoms family history ashkenazi jews (along with tay sachs and cavan's)

tubal ligation failure

may already have implementation or in process Surgical errors- getting round Technique errors, filshie clips fall off tubal re-anastomosis

uroflowmetry

measures rate and degree of bladder emptying Should have at lmeasures rate and degree of bladder emptying Should have at least 150ml The next step is recording the post-void residual volume to evaluate the extent of bladder emptying.east 150ml The next step is recording the post-void residual volume to evaluate the extent of bladder emptying. normal is less than 50 (or 3/4 emptying) Abnormal is >150

causes of hot flashes (general)

menopause POI - anxiety hypoglycemia - hyperthyroid carcinoid Meds (tamoxifen) Smoking, drinking.

physicial exam prior to TA

minimal physical examination consists of height , weight, vital signs pelvic exam. Further examination is directed by history. Rh status should be determined in all women. Ultrasound is recommended to determine GA - itra op US increases D&C success

pregnancy loss

miscarriage rates around 20% (depend on age) The majority of sporadic losses before 10 weeks' gestation result from random numeric chromosome errors, specifically, trisomy, monosomy, and polyploidy Recurrent pregnancy loss: defined by - two or more failed CLINICAL pregnancies. - three total (not consecutive) pregnancy losses A Clinical pregnancy is either documented by ultrasonography or histopathological examination - fewer than 5% of women will experience two consecutive miscarriages, - only 1% experience three or more

post partum cardiac monitoring

monitor for arrhythmia fluid shifts/overload PPH , with anemia VTE

monitor twins

mono-di: twice a week 16 to 18 weeks' gestation by assessment of amniotic fluid volume (AFV) and fetal bladder in both twins for early detection of TTTS. Furthermore, we begin measurement of MCA PSV in both fetuses at 26 to 28 weeks for early detection of twin anemia-polycythemia sequence (TAPS). There are inadequate data to determine the optimal frequency of monitoring, but measurement once a week is reasonable, with more frequent monitoring if abnormalities are detected (e.g., discordant AFVs that do not yet meet criteria for stage I TTTS). Di-di SOGC says serial sonographic assessment every 3-4 weeks, starting at 24-25 weeks gestation, appears to be a reasonable approach for uncomplicated dichorionic twins q2 weeks if growth discordance >20%

define tachysystole

more than five (6+) contractions in 10 minutes..... averaged over a 30-min window OR CTX's > 90 secs OR Uterus remains firm between contractions (25 mmHg) OR Resting rate of < 30 secs

how does a complete molar pregnancy present ?

most often asymptomatic, from ultrasound detection. - on histology - abnormal vaginal bleeding: - a large-for-date uterus - hyperemesis - hyperthyroidism. - early preeclampsia theca luteal cysts on ultrasound a rising hCG level will differentiate GTD from diagnoses such as a blighted ovum or missed abortion

anticholinergic contraindications

narrow angle glaucoma uncontrolled myasthenia urinary retention gastric retention, known hypersensitivity to the individual drugs or any of their ingredients Relative: impaired cognitive function reduced renal or hepatic function concomitant excessive alcohol use (added sedating effects) decreased gastrointestinal motility constipation controlled myasthenia gravis.

side effects of UTI antibiotics

nausea, vomiting Candida Hemolytic anemia with GSPD

after eclampsia seizure

neuro exam cervical exam prepare for delivery Workup for other causes Control BP

should you do ultrasound after cerclage in ?

no

risks for OASIS

nullipartity assisted delivery (especially forceps) post dates Macrosomia GDM upright position Shoulder dystocia Midline episiotomy

PMS

o At lest one Affective and Somatic symptoms, starting 5days prior to period, for at least 3 periods. " Must be severe enough to interfere with some aspects of life, like word and relationships" ▪ Affective: ● Depression ● Irritability ● Anxiety ● Anger outbursts ● Confusion ● Social withdrawal ▪ Somatic ● Headach. ● Breast tenderness ● Abdominal bloating. ● Swelling of extremity The American College of Obstetricians and Gynecologists (ACOG) define PMS as the presence of at least one symptom occurring in the luteal phase of the cycle, which leads to impairment in functioning. The International Society for Premenstrual Disorders (ISPMD) identified "core" criteria for clinically significant PMS to include at least one symptom that is either psychological or behavioral. The symptom(s) must impair functioning in some way and the symptom must remit at menses or shortly thereafter to constitute a symptom-free interval. To diagnose PMS, an obstetrician-gynecologist (ob-gyn) must confirm a pattern of symptoms. A woman's symptoms must - be present in the 5 days before a period for at least three menstrual cycles in a row - end within 4 days after a period starts interfere with some normal activities WIlliams Gyne: Diagnosis of PMS symptoms must begins at least 5 days or 1 weeks before menses and remits within 4 days after menses should use prospective daily symptom recordings occasionally, PMS symptoms may be an exacerbation of underlying primary psychiatric conditions

why wait for menarche before menstrual suppression

o Confirm normal HPO axis function o Confirm patent genital tract o Patient may cope better than caregivers expect and thus we are giving medications unnecessarily

describe mirena insertion start to finish

o Consent from patient and/or caregiver based on ability to do so o Pregnancy test if hasn't just completed her menses o Tanner staging and external genital exam o Bimanual o Speculum o Disinfection of the cervix o Tenaculum on the anterior lip o Sounding of the uterus with a sound o Insertion of IUD as per company instructions o Cut strings to 2-3cm o Remove instruments and check for bleeding

manage acute heavy bleeding

o Cyclokapron 1g IV or PO Q6H o Premarin 25mg IV Q4 -6H x 24hrs o Start OCP (Ovral BID) simultaneously o Use with anti-emetic!!

medical conditions and incontince (diappers)

o Dementia / delirium o Infection: UTIs o Atrophic vaginitis o Psychological o Pharmacologic: estrogen, α-adrenergic agonists, anti-psychotics, and diuretics o Endocrine: poorly controlled diabetes o Excess water intake o Restricted mobility o Stool impaction ▪ Urethral diverticulum ▪ Urogenital fistula Neurological condition (MS, Parkinson, Dementia, SC injury)

menstrual suppression options

o Expectant management o TXA +/- NSAIDso CHC : OCP, patch, ring o POP or implant o DMPA o LNG-IUS

considerations for offering menstrual suppression

o Medical history o Medications o Absolute CI to one method o Previous methods used o Goal - control (cycle/flow) vs suppression o Able to swallow pills o Picking at skin o Bone health o Ability to tolerate a pelvic exam o Tolerance for IM injections o Combining with other procedure o Risks of GA

tips to prevent perforation

o Performing bimanual exam prior to insertion o Using tenaculum and applying traction to cervix o Sounding uterus

GnRH sides

o Side effects: hot flashes, mood swings, insomnia, vaginal dryness, loss of libido, loss of BMD (sometimes not reversible)

what are the anti-androgens?

o Spironolactone ▪ 100-200 mg day ▪ Inhibits 5-alpha-reductase activity ▪ S/Es: transient diuresis, fatigue, headache, gastric upset, breast tenderness, theoretical feminizing effect on male fetus o Flutamide: ▪ 250-500mg daily ▪ Androgen receptor blocker ▪ S/E: hepatotoxicity o Finasteride: ▪ 5mg daily ▪ Androgen receptor blocker ▪ S/E: teratogenic potential

Danazol drug, mechanims, and sides

o Weak androgen o Suppresses GNRH, FSH, LH and estrogen & P o Contraindications: pregnancy Side effects: weight gain, acne, hirsuitism, breast atrophy, virilisation, hyperlipidemia

risks of obesity for mom

obesity is associated with an increased risk of chronic hypertension, type 2 diabetes mellitus, dyslipidemia, cardiovascular dis-ease, arrhythmias, stroke, osteoarthritis, non-alcoholic fatty liver disease, chronic kidney disease, depression, obstructive sleep apnea (OSA), and venous thromboem-bolism

when to suspect retroperitoneal hemorrhage? how to assess ?

occult retroperitoneal hemorrhage should be suspected in patients who have a deteriorating hemodynamic status more than 12 hours post surgery. In these cases, identification of the exact site of bleeding can be very difficult. Hemorrhage during or following an operative procedure should be addressed surgically; with immediate exploration, isolation, and ligation of bleeding vessels. In most cases, hemostasis can be achieved in this manner. Isolation and ligation of the uterine or internal iliac arteries are useful techniques to control hemorrhage in the pelvis. The ureter is especially vulnerable during the placement of hemostatic sutures in the pelvis. If hemorrhage continues, coagulation should be evaluated and any identified deficiencies should be corrected. Adjunctive measures such as radiologic embolization and packing of the pelvis should be considered in refractory cases.

mom risks of SLE

often correlate with disease activity, especially at baseline 1/3 worsen, 1/3 improve, 1/3 are stable Risk of flares ( risk of VTE (especially with anti phospholipid antibodies) thrombocytopenia - can have bleeding worsening kidney function HTN, preeclampsia (with it's risks, liver function, kidney function, stroke)

prolapse risk factors

older age smoking Obesity cough connective tissue disorders heavy lifting Pregnancy facors (multiparity, macrosomia, forceps) family history Menopause/hypo estrogen

risks for abruption

older age smoking cocaine hypertension trauma family hx previous abruption pprom twins

delay pregnancy after bariatric surgery

optimal duration unknown some places say up to 2 years Reasons - malabsorption during the post op stage - still losing weight, ideal to establish a more normal weight - potential complications of growrth restriction, PTB , anomalies

Ling vulvar HPV

options available See Public health guidelines on HPV/warts with a nice table. Medical - TCA (ablative) - liquid nitrogen (ablative) - podophylin - - imoquoid (immune modulator) 3x a week. patient admisistered - veregin (?Sp) ... similar to imoquoid. Surgical - excision - laser -

risk of PPH atony

overdistension - twins, macrosomia, multiples, fibroids, adeno, polyhydramnios , grand multiparity precipitous delivery protracted delivery oxytocin use prolonged second stage infection (chorio) placenta previa uterine malformations Uterine inversion Then tissue (RPOC) Trauma thrombin

prereqs for vaignal birth

patient consent- discuss risks/ benefits . Meltion trial of CS if failed Document exam Prepared staff Locateion to do CS Adequate analgesia Empty bladder

contraindications to pessary

patient declines patient non compliant with management allergy to material active genital infection

what can increase risk of infection or perforation of IUD

perforation 1) post partum 2) breast feeding 3) uterine anomalies 4) cervical stenosis 5) inexperienced operator (residents)

when is home birth reasonable?

persons with low degree of risk where the birth is anticipated to be uncomplicated and neither mother nor neonate will require resources beyond the local capacity.

evaluate primary amenorrhea Physical exam Labs

physical exam - Head and neck exam (thyroid stuff, goiter, lid lag) - - breast exam - genital exam (pubic hair, patent introitus) Labs hCG LH, FSH, E2, P4 TSH, Prolactin Testosterone, DHEA, DHEAS, 17OHP, androstenedione Consider progestin challenge test Pelvic ultrasound Consider karyotype - no uterus or uterine abnormality, Karyotype TSH, LH, FSH, E2, prolactin High prolactin- MRI Karyotype If high androgen, DHEA-S, free T, 17 OHP,

Endo workup pelvic pain workup

physical exam Look at the abdomen- inspection (scars, masses) Palpation - Peritoneal signs- guarding/rebound - carnett sign - appendicitis sign (Rosvig, Psoas, Obturator) - Murphy sign - flank pain/tenderness Exam of cervix, vagina, speculum - speculum - pap & swabs - pelvic (Uterine -size, position, mobility - Adnexa -masses/tenderness ) - Uterosacral ligaments (nodules, tenderness) - Rectovaginal (nodules) - Q-tip / pain mapping - pelvic muscles (kegels) - levator tenderness LABS CBC , ABO Pt/INR ESR , CRP hCG Urinalysis +/- culture STI testing Genital swabs Wet mount -ultrasound (look for sliding sign, adhesions, endometriomas, nodules ) -MRI if rectal symptoms: colonoscopy

main causes of amenorrhea

polycystic ovary syndrome hypothalamic amenorrhea hyperprolactinemia ovarian failure.

IDA pregnancy adverse outcomes

poor maternal comfort, maternal fatigue - maternal infection - PTB (and LBW) - FGR - adverse neurologic outcomes

How would you counsel the patient who tests negative for BRCA mutations?

possibly false negatives Still needs routine screening for other cancers due to family hx

when to treat asymptomatic BV

possibly pregnancy, mixed evience possibly before invasive gyne procedures - IUD insertion - termination - cerclage

PMDD

premenstrual dysphoric disorder - a condition associated with severe emotional and physical problems that are closely linked to the menstrual cycle. Symptoms occur regularly in the second half of the cycle and end when menstruation begins or shortly thereafter. Therapy for PMDD and PMS includes - psychotropic agents -ovulation suppression - dietary modification. Generalists may consider treatment of cases with mild-to-moderate severity. However, if treatment fails or if symptoms are severe, then psychiatric referral may be indicated. SSRIs are considered primary therapy for psychological symptoms of PMDD and PMS, and fluoxetine, sertraline, and paroxetine are FDA approved for this indication. ... Because gonadal hormone dysregulation is implicated in the genesis of PMS symptoms, ovulation suppression is another option. Some data support the use of COC pills in general for premenstrual mood symptoms. Moreover, in RTCs, Yasmin, a COC containing the spironolactone-like progestin drospirenone, showed therapeutic benefits. It carries an FDA indication for PMDD treatment in women who desire contraception. Alternatively, GnRH agonists are another means of ovulation suppression. These agents are infrequently selected due to their hypoestrogenic side effects and risks.

Risks for molar pregnancy

previous GTD family hx or GTD extremes in maternal age (>40 or <20) Asian

risks for twins

previous history race (ie, african herritage) advancing age family history Ovulation induction (ie, letrozole or clomid) Multiple ebryo transfer

risks for pprom

previous pprom family hx of pprom short cervix chorio systemic infection BV or other genital infections (GC) twins polyhydramnios trauma

risks of shoulder dystocia

previous shoulder dystocia family hx of shoulder dystocia instrumental delivery precipitous delivery CPD - narrow pelvis Asian race macrosomia GDM post dates

congenital CMV infection

primary CMV have around a 50% risk of infection to fetus .... (Around 20% of those infected infants have sequalae )

How does Mirena work ?

primary mechanism is cervical mucus foreign body reaction endometrial decidualization alters fallopian tube movement May occasionally inhibit ovulation

complications of massive trausfusion

reaction to blood anaphylaxis TACO, TRALI Acute hemolytic febrile, non hemolytic Hypocalcemia, alkalosis, hypokalemia thrombocytopenia Hypothermia coagulopathy

risks of egg retreival

reaction to sedation Bowel injury small risk of infection bleeding , injury to pelvic vessels Rupture of ovarian cysts

benefits of ASA

reduction of preeclampsia (especially severe) reduced gestational HTN Reduction of PTB reduction of SGA

Her b/w returns as IgG- and IgM+. You repeat the blood work 1 week later and she is IgG+ and IgM+. What is your plan?

refer to ID, MFM, pediatrics Serial ultrasounds are used to screen for fetal anemia and signs of hydrops, beginning at 18 weeks' gestation. Fetal anemia can be suspected with MCA PSV < ≥1.50 multiples of the median (MoM) If the MCA PSV values are <1.50 MoM, it is suggested to continue screening with weekly ultrasounds for 12 weeks after exposure If MoM > 1.5 but no hydrops, increase u/s to 2-3x a week for hydrops If hydrops is noted, fetal transfusion is warranted if it is confirmed by cordocentesis. Fetal transfusion is typically limited to 20-35 GA; the procedure is technically difficult before 20 weeks' gestation, and there exists excessive fetal risk compared to delivery beyond 35 weeks' gestation.... so deliver by 34-35 if hydrops.

gyne onc tumor workup

referral to gyne onc Ultrasound, consider MRI CT abdo pelvis CT chest

contraindications to epidural

refractory maternal hypotension maternal coagulopathy thrombocytopenia LMW heparin within 12 hr untreated bacteremia skin infection at injection site increased intracranial pressure causes by mass lesion

relapse vs reinfection UTI Which is more common

relapse- same bacterial strain persists reinfection- new organism is isolated or same organism is reintroduced Reinfection is more common

workup of thrombocytopenia

repeat CBC- use citrate anticoagulant HIV, hep C Preeclampsia workup liver function, kidney function, PCR autoimmune workup- ANA

prolactin workup

repeat in AM (fasting) BhCG TSH BUN/Creat MRI head

hydatidiform mole

result from an excess of paternal haploid chromosome sets in the gestation. Complete hydatidiform moles - typically characterized by the absence of a maternal haploid chromosome (completely dads) a) fertilization of an empty ovum by a single sperm with duplication of its chromosomes (i.e., monospermy: 46,XX) - most common b ) through fertilization by 2 sperm (i.e., dispermy: 46,XX or 46,XY). ¨ 46XX (90%) ¨ 46XY (10%) Partial hydatidiform moles result from similar processes but contain 1 maternal haploid chromosome set, resulting in a triploid gestation (i.e., 69,XXX 69,XXY 69,XYY). may have fetal parts and membranes..... This is in contrast to a triploid pregnancy with 2 maternal sets and only 1 paternal haploid set, where the conceptus is a non-molar triploid gestation exhibiting hydropic villi but no trophoblastic proliferation

theories of endo

retrograde menstruation Lymph spread Metaplasia

indications for WinRHO

routine 28 weeks and postpartum trauma bleeding Ectopic pregnancy Molar pregnancy (though only required for partial but still not wrong to give ) ECV Invasive procedures: - amnio - cvs - Cordo

mucinous tumor management on frozen

run the bowel check appendix consider complete staging

pre conception SLE

see rheumatology, thrombosis, MFM, maybe NICU , anesthesia Control disease activity avoid teratogenic meds: - ACEi's - methotorexate - mycophenolate Switch to pregnancy compatable meds - hydroxychloroquine - azathioprine - tacrolimus - prednisone - ASA, +/- heparin Caution on NSAID's , especially late in pregnancy

Lupus cerebritis

severe neurologic complications - headache - TIA - stroke - seizures - blindness - treat Full neurologic workup (CT, MTI, LP ) IvIG steroids

what are the OR risks of D&C with molar ?

significant hemorrhage ( Brisk bleeding is often encountered with serial dilatation of the cervix.) thyroid storm acute respiratory dysfunction from trophoblastic emboli. A suction catheter appropriate to the size of the uterus is then used to evacuate the uterine contents, which are sent for histologic examination. A delicate sharp curettage is performed at the end of the procedure to ensure complete evacuation.

risks of paternal age

small risk of ● Infertility/subfertility ● SAB ● Autosomal dominant diseases o Achondroplasia o Apert syndrome o Crouzon syndrome ● Autism spectrum disorders ● Schizophrenia ● Possible increase in T21 ● Congenital anomales

Maternal risks of operative delivery

soft tissue injury Pain, urinary intoneunce Blood loss anemia pyshologic injuries OASIS Second stage CS can lead to PTB

diagnose asthma

spirometry metacholine challenge test

figo GTN prognostic score

stage-I disease usually have a low-risk score (6 or less) - start with hyst if they do not desire fertility, then adjuvant single chemo - alternative start is single agent chemo (MTX-FA usually, or actinomycin D) - stage-IV disease have a high-risk score. go straight to combo chemo The distinction between low and high risk applies mainly to patients with stage-II or III disease. When the prognostic score is 7+, the patient is categorized as high risk and requires multimodal therapy, which includes intensive combination chemotherapy, and may include surgery and radiation to achieve remission. 12 + is ultra high risk

complications of ICP

stillbirth PTB meconium aspiration PPH

consequences of cesarean

subfertility OR 1.60 (95% CI 1.45-1.76), ectopic pregnancy OR 1.21 (95% CI 1.04-1.40) miscarriages OR 1.17 (95% CI 1.03-1.32) and stillbirth OR 1.27 (95% CI 1.15-1.40)

treat molar pregnancy

suction D&C Could consider a hyst Note: even if hysterectomy is selected, patients must be aware that they will still require serial hCG monitoring because the development of GTN requiring systemic treatment may still occur. The uterus must be removed intact (i.e., no morcellation). Follow-up must be the same as for those undergoing uterine evacuation, and treatment should be based on the final pathology results.

Hunner's ulcer

superficial erosion of the bladder mucosa in interstital cystitis

glomerulations

superficial ulcerations with pinpoint bleeding Glomerulation refers to bladder hemorrhages which are thought to be associated with some types of interstitial cystitis (IC)

DDX of post op infection

surgical site infection vault infection Pelvic abscess Pelvic hematoma bowel perforation/unjury, sepsis UTI

adverse sides of prostaglandins

tachysystole - that can cause uterine rupture of abnormal FHR meconium aspiration GI side effects (nausea, vomitng, diarrhea) fever Vaginal irritation

what is emergency contraception

taken after intercourse prevents implementation

cmv transmission and severity

the rate of transmission increases with increase in gestational age (highest in the third trimester)..... but the severity of disease is instead inversely proportional to gestational age (the infant is most affected when maternal infection is in the first trimester).

risk of invasive mole after molar pregnancy What are the risks ??

the risk of invasive mole is: 5% to 20% after a complete hydatidiform mole 0.5% to 1% after a partial hydatidiform moles. The risk of invasive mole increases to 40% to 50% in patients with any one of the following risk factors: -age >40 years - uterine size >4 weeks above expected for gestational age - hCG ≥100 000 mIU/mL - bilateral theca lutein cysts ≥6 cm.

ultrasound findings of congenital toxo

the so-called classic triad of congenital toxoplasmosis consists of -chorioretinitis -hydrocephalus - intracranial calcifications. However, the classic triad occurs in <10 percent of cases - growth restriction - fetal demise others= - microcephaly - ventricular dilatation - ascites - hydrops - hepatosplenomegaly - increased placental thickness . Neonatal consequences include: - Can have: - IUGR o LBW o Hepatosplenomegaly o Icterus o Anemia o Neuro disease Seizures - loss of vision with chorioretinitis (most common) - 10-30% have hearing loss - 20-75% have developmental delay

who to investigate for APLS

those with the criteria SLE prolonged apTT

pathogenesis of PPCM

thought to be due to- placental factors like increased SFLT-1- prolactin cleaved by Cathespin D to a 16 kDA fragment, causing endothelial apoptosis- Genetics

how to optimize natural infertility

time intercourse around 6 day window Check ovulation with kits Every 2 days is probably okay Avoid lubricants (except pre-seed is okay) Avoid smoking, lose weight, eat healthy Folic acid

when should you obtain a frozen section

to confirm pathology that will change your management, consider advanced staging - to confirm the lesion tissue is present - assess margins

manage anterior/posterior prolapse

traditional anterior (or posterior) repair / colporrhaphy Site specific repair possible augment with mesh

neonatal consequences of HIV

transmission FGR preterm birth

risk of HSV vertical transmission What are ultrasound findings?

transplacental infection is rare. First-episode primary infection during pregnancy can lead to - microcephaly - ventriculomegaly - spasticity - echogenic bowel, hepatosplenomegaly, and flexed extremities

follow syphilis response

trend VDRL titers

manage epigastric bleeding at laparoscopy

try and suture ligate with laparoscopy attempt to cauterize using another laparoscopic port · Place foley catheter through canula, inflate bulb, pull up towards abdo wall. Remove canula and place Kelly clamp to apply pressure. Leave X24hrs(?) · ligate above and below injury (Endo-close or full-thickness through skin) · Open incision, identify bleeding and ligate

Vulvar hygiene

type of underwear type of clothing washing of vulva, soaps, baths, etc. detergents wiping front to back

ectopic workup

ultrasound · CBC · G&S (determine Rh status) · Quantitative BHCG · LFT's · Renal function · Coags Progesterone- M6 model

investigate growth restriction

ultrasound evaluate for maternal medical conditions Consider amnio

can turner syndrome get pregnant?

unlikely, small chance, ~2% Options - egg donation - adoption

Winrho dose

up to 12 weeks- 120 mcg given at 28 weeks, and after birth 300 mcg Could also do 120mcg at 28 and 34 weeks 300 mcg protects against 30ml of fetal blood (15ml RBC's) In bleeding, recommnded to - still do a kleihauer - give Winrho - may need to give more if FMH is > 30ml (20mcg for every 1ml of fetal RBC) Note: Half life is 24 days, so could consider not giving it if they had received it within the last 21 days (but still do Kleihauer to see if they need extra)

once the uterus is inserted, how to remove placenta

use a fist to put it up Hold uterus in place with sponge on a stick

TSH targets per trimester

used to be T1- 0.1- 2.5 T2- 0.2- 3.0 T3- 0.3- 3.0 Now it often depends on presence or not of TPO antibodies TSH >4 with TPO antibodies TSH > 10 without antibodies In infertility- can aim slightly lower TSH < 2.5 with antibodies TSH < 4 without antibodies

prognosis of PPCM

usually good, most do recover ● Acute mortality 2% ● Long term mortality 18% ● Full recovery rate 28% ● Most deaths occur within 3 mo PP ● Deaths usually caused by: o Progressive heart failure o Arrhythmias o Thromboembolic events

risks of IBD in pregnancy

usually, correlates with the degree of disease activity ... especially if well controlled and for a long time. Active disease can slightly lower fertility rates of getting pregnant.

types of VwD

vWD *type 1- quantitative*, 75-80% pts, mild-mod bleeds VWD *type 2- qualitative*, 15-20% pts, mod-severe bleeds VWD *type 3- quantitative*, very rare, really severe bleeds

how to prevent recurrent UTI

vaginal estrogen cranberry Post coital ABX prophylaxis continuous prophylaxis on demand treatement Possibly voiding after intercourse Controlling medical conditions

What are the physiological changes to cervix which limit colposcopy in pregnancy:

vaginal walls collapse columnar cells evert leads to more metaplasia increased vascularity and cx more friable more cervical mucus blood vessels pattern can mimic Ca

what are the response rates for high dose progestins?

very effective. Response around 75% Recurrence around 30%

prolapse exam

visual inspection perineal sensation Cough test (supine and standing) urethral q-tip test Split speculum test for prolapse kegels bimanual

what do you monitor during hemorrhage resus

vital signs, urine output, cap refill, menal status regular checking of: electrolytes hemoglobin coag factors acid base status / lactate

surgical staging

washings upon entry thorough inspection of the pelvis check the uterus, other ovary, omentum, possibly bowel, peritoneum Biopsy suspicious tissue Send for frozen section Palpate the pelvic and para-aortic nodes .... staging has pelvic/par aortic lymphaeenectomy Omentectomy

post molar follow up

weekly hCG, starting 2 weeks after the D&C Do it weekly until negative for 3 consecutive weeks MUST use reliable contraception Must see 6 weeks post op Partial: hCG should be measured 1 month after the first undetectable result to confirm resolution e- Oct 3, Oct 10, Oct 17 .... Then Nov 3 Complete Monthly monitoring should continue for 6 months

reassuring factors for SLE in pregnancy

well controlled disease no anti-phospholipid antibodies no renal disase, or other organ sequalae well controlled BP Disease controlled on meds that are not teratogenic (hydroxychloroquine, tacrolimis...

PCOS criteria

what is PCOS ? condition with insulin resistance, elevated synthesis of ovarian androgens, causing development of follicles , and menstrual irregularity. a diagnosis of PCOS is based on at least 2 of the following 3 criteria: 1) oligo-ovulation or anovulation 2) clinical OR biochemical evidence of hyperandrogenism (hirsutism, acne, alopecia, virilization, infertility), 3) polycystic ovaries on ultrasound assessment (> 12 small (2-9mm) antral follicles in a single ovary) the exclusion of medical conditions such as : - congenital adrenal hyperplasia - androgen-secreting tumours Also need to rule out - Cushing's syndrome - Prolactinoma - Thyroid disorders - Premature ovarian insufficiency

itching in pregnancy ddx

what is your differential diagnosis? ● ICP - pemphigoid gestationis - atopic erruption pregnancy ● Viral hepatitis (A/B/C) ● Acute fatty liver of pregnancy ● Cirrhosis (alcoholic liver disease)

maternal trauma, details of accident

when did it happen how fast Seatbelt rapid deceleration

parvo in fetus mechanism

when maternal parvovirus infection occurs during pregnancy, the virus can cross the placenta and infect red cell progenitors in the fetal bone marrow..... this suppresses erythropoiesis, thereby resulting in severe anemia and high-output congestive heart failure It also affects the heart- causes myocarditis Affects the liver/hepatocytes

risk of coexistent endometrial carcinoma in hyperplasia vs atypia

without atypia, <1% with it, like 60%

UTI prophylaxis pregnancy

women with HX of recurrent UTI's a UTI with a medical condition that increases risk (diabetes, sickle cell) 2 or more UTI's in pregnancy Pyelo in pregnancy

what else associated with high AFP

wrong dates ● Cystic hygroma ● Sacrococcygeal teratoma ● Abdominal wall defect - omphalocele and gastroschisis ● Renal anomalies ● Urinary obstruction ● Cloacal extrophy ● Esophageal or intestinal obstruction ● Liver necrosis ● Osteogenesis imperfecta ● Congenital skin abnormality

vaccines contraindicated in breast feeding

yellow fever typhoid smallpox herpes zoster

prior to placing veress checks

£ Check spring function Attach gas tubing to ensure low pressures (that veress needle not blocked)

post laparoscopy abdominal pain history

£ Onset of abdominal pain £ Location £ Duration £ Characteristic (sharp, burning, cramping) £ Severity £ Radiating £ What improves £ What makes it worse £ Fevers, chills £ Nausea and vomiting £ Appetite £ Abdominal distension £ Is the patient passing flatus £ Any other sites of pain £ Any urinary symptoms Bleeding

Causes of irregular bleeding with Mirena in

£ pregnancy £ infection £ expulsion £ malposition - perforation £ gynecological pathology

treatable causes of hydrops

§ Arrythmia § Anemia § TTTS § Hyperthyroidism

first trimester bleeding physical exam

¨ ABCs, vitals, height, weight, BMI General inspection ¨ CVS/Resp ¨ Abdo - inspection (previous scars), size of uterus, tenderness, peritoneal signs ¨ Pelvic - speculum (to assess bleeding, tissue), V/E to determine cervical dilatation & tenderness

complete molar pregnancy orders

¨ Admit to GYNE ¨ NPO ¨ AAT ¨ VS frequently (depending on blood loss) ¨ IV NS at 125cc/hour ¨ CBC, G&S, PT, INR ¨ Cross match 2 units (consider) ¨ CXR TSH

management of HIV in pregnancy

¨ Multidisciplinary team o Peds, ID, MFM ¨ Routine antenatals o VDRL, Hep B, Rubella o CBC (thrombocytopenia), Rh, antibodies o Pap smear o GC/Chlamydia ¨ HIV o Viral load o CD4 count o Hep C o Toxo IgG, IgM o TB skin test o CXR o VDRL important - syphilis can increase risk of HIV transmission Baseline viral load ¨ Counseling ¨ Offer combination antiretroviral regardless of viral load and CD4 count...... some placed start in early T2 ¨ Monitor CD4 count and viral load from time of diagnosis, q 4-6 weeks (minimally q trimester) ¨ Monitor for toxic effects of HAART (esp with neveripine) Consider antibiotc prophylaxis based on CD4 count Give vaccines!!!! - influenza, Hep B, pneumococcus, meningococcus ¨ Early glucose intolerance screening - protease inhibitors can potentiate hyperglycemia (there is potentially an increase in DM in these patients)

risks for HIV vertical transmission How can you reduce?

¨ Preterm birth ¨ Prolonged ROM ¨ Concurrent syphyllis ¨ Chorioamnionitis ¨ Maternal viral load - AIDS definiing illness If possible, AVOID - Instrumental delivery - internal monitoring - episiotomy - fetal blood sampling - prolonged ARM (keep membrnes in tact as long as you can) - if ARM, try and deliver within 4 hours - avoid CVS/amnio - avoid ECV

DDX first trimester bleeding

¨miscarriage (inevitable, threatened, incomplete, complete) ¨ Ectopic ¨ Molar ¨ Cervical polyps/malignancy/infections ¨ Vaginal trauma/infections

what candidates are good for pregnancy after renal transplant

· 2 year interval after transplant · No evidence or episodes of rejection · Anti-rejection meds are at maintenance level · Anti-rejection meds are non-teratogenic · Cr <177 but better if <110 · Proteinuria < 500 mg/24h · Minimal to no hypertension

cat 3 CHC

· 4-6 wks PP (breastfeeding w/ risk factors for VTE eg. age >=35, previous VTE, immobility, transfusion at delivery, -peripartum CM, BMI >= 30, PP hemorrhage, C-section, PIH, smoke) · DVT/PE on established anticoagulation therapy w/ no other risk factors for VTE · Hx of DVT/PE w/ lower risk of recurrent DVT/PE (no other RF for VTE) · Multiple sclerosis w/ prolonged immobility · Smoker aged >= 35 (<15 cigarettes/day) Multiple risk factors for arterial CV disease (eg. older age, smoking, DM HTM, low HDL, high LDL, high TG level ) · Adequately controlled HTN SBP 140-159mmHG or dBP 90-99mmHg) · Peripartum cardiomyopathy w/ normal/mildly impaired cardiac fxn >6 months · Hx breast CA and no evidence of disease for 5 years · Symptomatic gallbladder disease (current or medically treated) · Acute or flare of viral hepatitis (for initiation only) · DM with nephropathy/retinopathy/neuropathy, other vascular disease or DM >20 years duration · Past COC related cholestasis Hx of malabsorptive bariatric procedures (Rous-en-y bypass, biliopancreatic diversion)

cat 4 chc

· <4 weeks PP (breastfeeding) · Smoker >35 years (>15 cigarettes/day) · Vascular disease · HTN (sBP>=160mmHg or diastolic >=100mmHg) · active Acute DVT/PE · History of DVT/P, not receiving anticoagulation therapy · Known thrombophilia - Current and/or history of ischemic heart disease · Complicated vulvar heart disease (pul HTN, risk of A fib, Hx subacute bacterial endocarditis) · History of stroke · SLE with +ve (or unknown) antiphospholipid antibodies · Migraine with aura · Peripartum cardiomyopathy w moderately/severe impaired cardiac functionHx of estrogen associate DVT/PE), pregnancy associated VTE/PE, idiopathic DVT/PE, known thrombophilia, Hx of recurrent DVT/PE) · Major surgery with prolonged immobilization · Current breast cancer · Severe decompensated cirrhosis · Hepatocellular adenoma Complicated solid organ transplantation (graft failure)

perimenopausal bleeding history

· Age, G, P, LMP · PObsHx · Bleeding Hx: o Duration of bleeding o # pads/day, ?clots/flooding o Symptoms of anemia o Relation to I/C o Prev Rx o Dysmenorrhea o Dyspareunia IMB ? · Menopausal symptoms: Hot flushes, vaginal dryness, sleep disturbance, etc. · GynHx: o STI's/PID o Paps o Fibroids, polyps, cysts · Recent Invx: U/S · Constitutional symptoms · PMHx: coagulopathy, DM, thyroid, BMD, mammograms · PSurgHx · Meds, Allerg · Smoke, EtOH, Street drugs, SocHx B symptoms- weight loss, night sweats, fever ?

risks for osteoporosis

· All women over 50 should have an osteoporosis risk factor assessment, and DEXA scan if: o 1 major risk factor o 2 minor risk factors · Major RF's: over 65, fragility fracture over 40, vertebral compression fracture, glucocorticoids for 3 months, malabsorption, primary hyperparathyroidism, propensity to fall, hypogonadism, POF, osteopenia on Xray · Minor RF's: rheumatoid arthritis, past history hyperthyroidism, anticonvulsants, low dietary calcium, smoker, excessive Etoh, caffeine, smoking, low weight

How does endo present?

· Asymptomatic - Dysmenorrhea · Dyspareunia · Cyclic hematemesis/ hematuria/ hematchezia · Ovarian mass (?endometrioma) · Infertility Chronic pelvic pain

symptoms of high prolactin

· Asymptomatic · Headache · Bitemporal hemianopsia (peripheral vision defects) · Galactorrhea · Oligo or amenorrhea - poor libido

adnexal mass categories

· Benign o Endometrioma o Dermoid o Cystadenoma o Functional ovarian cyst o Ruptured / hemorrhagic ovarian cyst o Diverticulosis o Pelvic kidney · MALIGNANT Epithelial Germ cell Sex cord stromal o Endometrial CA o Sarcoma o GI malignancy o Lymphoma

macroprolactinoma follow up

· Consult endocrinology/neuro surgery · Further investigations o Visual field testing o Pituitary reserve testing · Medical therapy (bromocriptine or cabergoline) · Follow up o Monitor PRL Q3mths o MRI 4mths after starting meds to confirm decrease in size

adnexal mass pregnancy ddx

· Corpus luteum (90% T1) · Simple cyst · Benign cystic teratoma (30 - 50%) · Serous/mucinous cystadenoma (20 - 30%) · Endometrioma · Other benign cyst (~7%) o Paratubal cyst o hydrosalpinx · Pregnancy luteoma (solid) · Theca lutein cyst (multicystic) · Malignant/Borderline (5-10%) · Fibroid (pedunculated)

List possible non-contraceptive benefits to CHC use:

· Cycle regulation and predictable withdrawal bleeds · Decreased menstrual flow · Decreased anemia · Increased BMD, + during later reproductive years · Decreased dysmenorrhea · Decreased incidence or severity of PMS and PMDD · Decreased perimenopausal symptoms · Decreased acne Decreased hirsutism · Decreased risk of fibroids · Decreased endometrial cancer · Decreased ovarian cancer · Fewer functional ovarian cysts due to impaired folliculogenesis · Lower risk of benign breast disease · Decreased colorectal carcinoma · Decreased incidence of salpingitis Reduced pelvic pain and less recurrence of dysmenorrhea and endometriomas associated with endometriosis

endometriosis surgery

· Depends on whether pt symptomatic · If incidental finding - LEAVE IT ALONE! · If symptomatic o Ablation/excision of superficial lesions o Excise endometriomas >3cm o Adhesiolysis to restore normal anatomy - consider interceed o Methylene blue for tubal patency o Treat deeply infilitrating endo · Post-op start continuous or cyclic OCP o Decreased recurrence endometrioma o Improves pain management · Canadian collaborative group on endo showed Rx of mild-moderate endo at laparoscopy increased pregnancy rates o NNT = 8 laparoscopies for 1 pregnancy

confirm veress entry

· Feeling double-click · Low CO2 filling pressures (<10mmHg) · Saline-drop test · Symmetrical abdo expansion

Risks of fetal transfusion:

· Fetal distress req'ing delivery · Failed procedure · Fetal death (1-2%) · PTL · Infection · Bleeding (fetal/maternal) · PPROM

physiology of hydrops

· Heart failure from profound anemia and hypoxia · Portal hypertension from hepatic dysfunction secondary to extramedullary hematopoiesis · Decreased colloid oncotic pressure from hepatic dysfunction and hypoproteinemia · Capillary leakage from tissue hypoxia · Myocarditis in Parvovirus infection

fetal hyperthyrodism treatment

· If at or near term, deliver · If remote from term, maternal treatment with thioamides

ddx of rise in insufflation pressure

· Kink in gas tubing · Lack of adequate anesthesia (pt straining) · Veress needle located in: o Omentum o Bladder o Bowel o Vessels o Retroperitoneum

Name some oft markers

· Likelihood Ratios of soft markers for aneuploidy (SOGC): · Increased NF: 17 for T21 · Echogenic bowel: 6 for T21 · Ventriculomegaly: 9 for T21 · Echogenic Intracardiac focus: 2 for T21 · Choroid Plexus Cyst: 7 for T18 · Single UA (renal, cardiac), Renal pyeliectasis (reflux) and enlarged cisterna magna o If isolated, no increased likelihood of aneuploidy but may be assoc'd with other congenital anomalies

manage cardiac disease labor

· Multidisciplinary approach, anesthesia, cardiology, MFM · Consider IOL, during day when all teams available · Plan vaginal delivery unless contraindicated for obstetric reasons · Continuous maternal and fetal monitoring · Labor in left lateral decubitus · Oxygen · Close monitoring of fluid balance try and keep as euvolemic as possible · Continuous cardiac monitoring (EKG) + invasive monitoring (Swan-Ganz) · Epidural - êes catecholamines (but watch for hypotension) · Shorten 2nd stage (vacuum or forceps) Endocarditis prophylaxis

manage cardiac cases in labor and delivery

· Multidisciplinary approach, anesthesia, cardiology, MFM, ICU · Consider IOL, during day when all teams available · Plan vaginal delivery unless contraindicated for obstetric reasons · Con

indications for surgery with macroadenoma

· No decrease in tumour size with therapy (? non fxning but compressing stalk) · Persistently increased PRL · Worsening symptoms

how long to inhibit ovulation cocp?

· Ovulation is effectively inhibited after 7 consecutive days of CHC use · Back-up contraception (barrier method) and/or abstinence should be used for the first 7 consecutive days of CHC use, unless it is initiated on the first day of menses.

ectopic symptoms

· Pain -95% · Amenorrhea - 80% Abnormal vaginal bleeding - 50%

mechanism of COCP

· Principal mechanisms of action = suppression of pituitary gonadotropin secretion, inhibiting ovulation · All CHC progestin dominant, progestin effects exceed estrogen component · Progestogenic component: o increases cervical mucus viscosity, impairing sperm transport o suppress LH and impairs ovulation (if follicle development escapes estrogen suppression) o effects tubal transport · Estrogenic Component: o Impairs folliculogenesis via negative feedback on FSH, potentiates effects of progestins o Allows for lower progestin dose o Stabilizes endometrium (improved bleeding pattern)

prolactinoma pregnancy

· Routine prenatal investigations/ultrasounds · PRL levels of NO value in pregnancy · Stop meds once pregnancy achieved · Monitor for symptoms - headache, visual field defects · With macroadenoma o Consider visual field testing Qtrimester (<5% chance growth) o Consider restarting bromocriptine if symptoms develop/worsen

uterine artery fibroid embolization indications

· Symptomatic fibroids (would otherwise advise surgery) · Medical contraindications to surgery · Unwilling to accept transfusion · Previous unsuccessful fibroid surgery · No future fertility plans *MUST be willing to accept hyst

ectopic kinds

· Tubal - Ovarian · Cervical ·abdominal - Isthmic - cesarean

placenta previa bleeding at CS How to manage ?

· Uterotonics as per atony · Vasopressin into the placental bed · Sutures in the placental bed · Bakri balloon · Vessel ligation · Pelvic artery embolization · Hysterectomy

What are the risks of CHC use? ____/2

· VTE o COC have 2-3 fold increase risk of VTE vs non-users o Non-pill users 4-5/10,000 vs COC 10/10,000 women years risk VTE · Cerebrovascular accident (stroke) and MI o Low dose COC (<50mcg ethinyl estradiol) are not associated w/ increased risk of MI or CV accident in women with NO additional risk factors · Gallbladder disease o Does NOT appear to be increase in gallbladder disease in COC users o COC use increased secretion of cholic acid in bile and decreases GB motility, potentially leading to higher incidence of gall stone formation

Post menopausal adnexal mass physical exam

ð General appearance .............................................................................. ð Vitals .................................................................................................... ð Height and weight - BMI ....................................................................... ð Palpation of LN § Supraclavicular .............................................................. § Groin .......................................................................... ð Chest auscultation (pleural effusions, consolidation) Breast and axillary examination ( breast malignancy) ð Abdominal examination § (Masses, organomegaly , ascites § ð Pelvic examination -bimanual and rectovaginal § Masses - characterize ...................................................... - Fixed or mobile, firm, nodular or smooth, bilaterality, tenderness, extension to parametrium, bladder/rectum abnormalities

Parvovirus history

ð History of previous infection with parvovirus ð Any previous documentation of serology ð What was the nature and duration of her exposure ð What was timing of exposure - before or after development of rash? ð GA at exposure ð Any maternal signs/symptoms of infection

fetal risks of IUGR

ð Intrauterine fetal demise .........................................................................................___/1 ð NRFHR in labour..................................................................................................___/1 ð Intrapartum asphyxia ............................................................................................___/1 ð Pre-term birth ......................................................................................................___/1 ð Malpresentation..................................................................................................___/

does a hyst improve endo pain?

ð Only if combined with bilateral oophorectomy to produce surgical menopause... ð Pathology related to hormonal status/ovarian function, not presence or absence of uterus

parvo tranmission

ð Respiratory secretions (most common) ð Hand-to-mouth contact ð Vertical transmission ð Blood products (rare)

parvo incubation

ð Viremia is 4-14 days post exposure (adult symptoms occur here) and Day 15 rash occurs ð Generally not infectious once rash has developed

growth restriction management

ð Weekly ultrasound for fetal well-being .......................................................................___/1 ð Ultrasound evaluation of interval growth.......................................................................___/1 ð Daily Kick counts ................................................................................................___/1 ð Celestone to be discussed (if abnormal Dopplers) ...........................................................___/1 ð Pediatric consultation...........................................................................................___/ Never wrong to consider admission, more frequent NST

seizure management

• ABCs - protect airway, 02 • Call for help o Anesthesia o Medicine/neuro • Prevent maternal trauma • Roll on size to minimize aspiration • Vitals - esp BP to determine whether could be eclampsia • Assess FHR - CFM if possible • IV start when able • Labs: o CBC o lytes, glucose o BUN, Cr o AST, ALT o INR, PTT, fibrinogen o Urine protein o Tox screen • Anti-seizure medications o Lorazepam 1-2mg Q5min IV, max 5 - 10mg (0.1mg/kg) o Phenytoin 50mg/min IV, max 1-2g o Valproic acid • If status epilepticus - consider head imaging and LP

. What is your differential for antepartum hemorrhage?

• Abruptio placenta - 40% • Placenta previa - 20% • Bloody show • Genital tract bleeding - polyp, malignancy, vaginitis • Vasa previa • Uterine rupture • Idiopathic/NYD - 35%

advantages and disadvantages of labor over CS

• Advantages of trial of labour: - Faster recovery - Less blood loss - Less infections - Less effect on future pregnancies/surgeries • Disadvantages of trial of labour: - Damage to pelvic supports of bladder, uterus, and rectum - Early onset urinary incontinence - Anal incontinence of flatus or stool or both - Dysparunea from descensus or vaginal scarring - "Loose vagina" with sexual dysfunction - Pain - Need for emergency C/S increasing risk over elective C/S - Adverse reaction to anesthesia or pain medication

Alternative treatments PMS

• Can be prescribed cyclically (ie: Day 14-28) • OCP • Spironolactone (for symptoms of bloating) • Exercise Extreme cases: oophorectomy What are other criteria for surgical management? • Confirmed diagnosis with prospective symptom recording • GnRH agonist must be the only therapy that was effective, and must have been effective for 6 mos. • Tolerance of E2 replacement therapy must have been tested during GnRH agonist therapy • Childbearing is completed. • The need for several more years of therapy must be anticipated

epilepsy anomalies

• Carbamazepine o NTD, fetal hydantoin - 1-2% • Phenytoin o Hydantoin syndrome, craniofacial abnormalities, facial clefts, cardiac abnormalities, IUGR, developmental delay - 5-11% • Valproic acid o NTD's - 1-4%

Advantages of CS Disadvantages

• Certainly CS does have some advantages: - Predictable timing - Less pain during birth - Less chance of shoulder dystocia - Less prolapse/incontinence but risk still present with pregnancy • However there are many disadvantages too: - Death/disability from anesthesia reaction, infection, blood loss - Long recovery - Poor healing, unaesthetic scar - Uterine rupture in future pregnancy - Injury to adjacent structures such as bladder and bowel - Elevated risk of placenta previa, placenta accreta in future pregnancy - Iatrogenic prematurity - Possible need to have a CS next pregnancy - Risk of CPP and adhesions making further surgeries more dangerous •

what to do immediately before cerclage

• Confirm the viability of the pregnancy by ultrasound • Exclude significant malformations • Determine whether there is a significantly elevated aneuploidy risk by T1 NT screening, if possible combined with serum marker screening • Urine C&S & vaginal cultures for BV should be taken,.... & any infection treated

cardiac changes in pregnancy

• Elevated CO by 40-50% o Further increase in CO with CTX in labour(10-15%) & PP (20-30%) with autotransfusion • HR increases by 10-15 bpm • Plasma blood volume increases by 50% o Plasma volume > red cell mass = anemia of pregnancy • BP decreases by 10-15 mmHg o dBP > sBP o Due to drop in SVR o Nadir at 26-28 wks

first vs second trimester screening

• FTS - done earlier, results earlier, decide on invasive testing for timing of TA if desired, BUT higher false positive rates and lower DR, CVS available in area? No testing for oNTD's. • IPS - lower FP rate and higher DR's, fewer invasive tests will be done, BUT need to wait until after 2nd step for results

What are the complications of placental abruption?

• Fetal o Death, anemia, hypoxia, preterm birth • Maternal o Hemorrhage/shock o DIC due to fibrinogen split products, consumptive, 30% risk when abruption severe enough to kill the fetus o Renal failure when failure to replace volume or transfuse, increased risk when preeclampsia, 75% of cases are ATN but may get acute cortical necrosis o Couvelaire uterus Extravasaton of blood into the myometrium, can extend into serosa and broad ligament Seldom interferes with uterine contraction o Death

fetal risks of labor vs CS

• Fetal risks of trial of labor - Intrauterine hypoxia with cerebral palsy ranging from mild to severe - Brachial plexus injury, especially with breech or shoulder dystocia - Injury from instrumental delivery

cardiac station exam

• General appearance, BMI • VS: BP, HR, SaO2, temp, RR • Cardiac exam: S1S2, murmurs, rhythm, JVP • Respiratory: air entry, effusion, crackles • Abdominal: palpate uterus, HSM peripheral edema • Vaginal exam: cultures, PAP On cardiac exam you hear a normal sinus rhythm at 78 and a 4/6 systolic murmur. The rest of the exam was normal.

mode of delivery in cardiac

• Literature describes vaginal delivery in > 75% • C/S usually for obstetrical indications (cardiac indications rare) • Most recommend vacuum/forceps to shorten second stage Recommend EPIDURAL b Minimizes fluctuations in HR, BP, CO with labour

risks of T1DM in pregnancy Maternal Fetal Neonatal

• Maternal o SA o HTN/PET - 40% overall, 66% if nephropathy, 20% if not o Operative delivery, C/S o DKA - 1%, 20% fetal mortality Hyperemesis, o Infections - UTI, pyelo, candidiasis, skin infections o Worsening proliferative retinopathy o ? worsening nephropathy if severe chronic dysfunction o gastropathy can be difficult to manage o Postpartum thyroiditis • Fetal o SA o Stillbirth - 1%, increases after 35 weeks, not related to glycemic control always o Anomalies - 5-10% overall, glucose control 20-25% if HbA1c >10% o macrosomia o shoulder dystocia, birth trauma o polyhydramnios o IUGR o Preterm birth - spontaneous and iatrogenic o Perinatal mortality - 2-4% • Neonatal - RDS/ TTN o Hypoglycemia o Hypocalcemia o Hyperbilirubinemia o Polycythemia o Hypertrophic cardiomyopathy o Injuries from birth o Mortality o Inheritance diabetes - 1-2%, 6% if only father, 20% if both parents

counsel T1dm in pregnancy

• Maternal risks • Fetal risks • Glycemic control - improves risk of anomalies, complications o Important!!, targets are strict o Goal HbA1c <7, 6 ideal - for 3 months before conception • Evaluate complications o Nephropathy, neuropathy, fundoscopy NEEDED!! o Optimally manage any abnormalities • Folic acid 5mg and multivitamin for three months • Discontinue ACEis/ARB/statins • Consider switching to insulin if type 2 DM on oral meds • Baseline bloodwork o CBC, G+S, 24 hour urine, creatinine, BUN, AST, ALT, HbA1C, TSH, ECG, echo • IOL at 37-38 weeks due to risk late stillbirth

normal cardiac exam findings pregnancy

• Mildly increased JVP • Diffuse apex pulsation • Split S1 + S2 • Occasional S3 • Midsystolic flow murmur

salpingectomy counselling

• Nature of the procedure o Considered permanent o Requires surgery- laparoscopy, hysteroscopy o Still menstruate, not same non-contraceptive benefits as others (OCP) • Benefits o Very effective contraception, low failure rate • Depends on type - overall 0.1-0.4% per year • 10 year cumulative rate about 1.85% overall o Decreased risk of ovarian cancer • Risks of failure o Ectopic pregnancy - 33% will be ectopic, a life threatening condition that can require surgery • 10% with clip or ring • 65% with electrocautery • Regret and reversal o 20% regret if younger than 30 years o 6% if over 30 years o 93% overall no regret o Reversal requires laparotomy and all of its risks • 50-70% successful pregnancy with reversal • increased risk ectopic as well - 10% • Surgical logistics and risks o Need informed consent o Required GA with associated risks, time off work o Laparoscopy risks - bleeding, visceral injury, infection, VTE -1/1000 o Overall death 1-2/100, 000 • Alternatives o Mirena IUS (0.1% failure), long acting hormonal, OCP o Vasectomy - less risk to male partner than tubal to her • Contraception until the procedure o Beta on day of surgery o Implantation occurs day 6 and chance conception right before procedure, no way to detect it

neonatal risks of FGR

• Need for intubation at delivery • Low Apgars, pH <7.0 • Hypothermia • Hypoglycemia • Polycythemia • Hyperbilirubinemia • Seizures • Sepsis • Neonatal death • Most otherwise healthy fetus will "catch up" by 2 yrs, but prognosis depends on etiology of IUGR • SGA infants at increased risk of HTN and CV disease as adults Cesarean Intellectual disability abnormal FHR instrumental delivery ð....................___/1 ð Hypo - natremia, -kalemia ......................................................................................___/1 ð Hyper - phostphatemia, -bilirubinemia ........................................................................___/1 ð Hypocalcemia.....................................................................................................___/f

Sexual assault STI prophylaxis, when and what to give?

• Offer if: o Unsure of whether patient will return for follow-up o It is known assailant infected o Requested by patient/parent/guardian o Patient has signs or symptoms of STI • May be appropriate to routinely offer prophylaxis of vaginal, anal penetration because most victims do not return for follow-up Gonorrhea - Cefixime 400mg po once (also if pregnant), ciprofloxacin 500mg po single dose Chlamydia - Azithromycin 1 gram po once, doxycycline 100 po bid for 7 days Trichomonas - Flagyl 2g po once

describe process of RR BSO

• Pelvic washings • Thorough inspection of all peritoneal surfaces o Diaphragm o Liver serosa o Omentum o Bowel o Paracolic gutters o Appendix • Thorough inspection of all pelvic structures o Ovaries o Fallopian tubes o Uterus o Bladder serosa o Cul-de-sac • Biopsy of any suspicious surfaces • Removal of the entire ovary and fallopian tube • Securing the IP ligament at least 1-2cm distal from the ovary

What important diagnoses must be considered in your differential for PMS

• Primary mood or anxiety disorder • Menopausal transition • Thyroid disorder • Substance abuse • Also: • Lupus, Endometriosis, Anemia, Fibromyalgia, Chronic fatigue, Fibrocystic breast disease, IBS and migraine

concerning cardiac signs/symptoms in pregnncy

• Progressive SOB • PND or orthopnea • Nocturnal cough • Hemoptysis • Syncope • Chest pain • Cyanosis • Clubbing • Persistently elevated JVP • Systolic murmur >3/6 • Diastolic murmur • Persistent arrhythmia • Cardiomegaly

What are the risk factors associated with development of a RVF from a vaginal delivery (in the developed world)?

• Prolonged second stage • Forceps • Shoulder dystocia - ? macrosomia • Midline episiotomy - improperly repaired, complications • Infection • Immunosuppression • IBD • Repeated trauma to the area

Incontinence questions

• Questions to identify SUI (leak with laugh, cough, sneeze, etc) /5 • Questions to identify urgency incontinence (make it to BR on time etc) /5 • Urinary frequency: q1-2hrs (increased), nocturia: 2-5x (abn) /5 • Pad use (2/day) (significant leak, she feels wet all the time) /5 • UTI/IBE/bowel habits/sexual activity /5 • Fluid intake: 4-5 water/day, freen tea once/week (caffeine sources) /5 • Meds (none) /1 • Allergies (NKDA) /1 • PSHx: D&E (malformations) 2013, Emergency CS term 2014, Emergency C/S 2020 - symptoms started immediately after /1 • Social: non-smoker, no drug use /1 • ROS: nil /1

Assess PMS

• Record symptoms and cycles prospectively for at least 2 months.

rectovaginal fistula repair

• Refer to experienced surgeon • Timing controversial ○ Immediate (early debridement & wound cleansing repair ~1 week) vs. Waiting 8-12 weeks for inflammation to decrease ○ Some small fistulas heal on their own • Non-invasive ○ Antibiotics, low residue diet ○ Fibrin glue

screening options in pregnancy

• Trisomy 21, 18, open neural tube defects (oNTD) • Should be offered to all women regardless of age o Maternal age alone should be abandoned, DR40%, FP 15% • Options - maternal age incorporated o FTS - 11-14 weeks Nuchal translucency PAPP-A, free -hcg o Second trimester quad screen - 15-20 weeks MSAFP, uE3, -hcg, inhibin-A

antepartum hemorrhage exam

• Vitals • FH • Bedside ultrasound for placental location - clear of the os • Head and neck • Cardiac and respiratory • Abdominal exam - tenderness, uterine irritability, contractions, fetal position • tocometer • Pelvic - speculum exam once placenta confirmed to be clear, digital exam for cervical diltation

consequences of PPCM

•Heart failure is most common• 20% arrhythmia, 4% V-tach, 2% have arrest• ~7% chance of VTE

what factors increase risk for uterine rupture ?

•IOL with cervical-ripening pharmacological agents •Use of oxytocin for augmentation or induction •2 or more prior CSs •Short interpregnancy delivery interval <18 months •Thin LUS •Classical or low vertical uterine incision

Hep C risk factors

•intravenous drug use •co-infection with HIV •exposure to infected blood or body fluids through contact with needles or medical devices (health care workers) •history of long-term hemodialysis •blood transfusion or organ transplant before 1992

risks for vaginal cancer

€ Advanced age. € HPV infection (cervical or Vulvar) € CIN, VAIN, VIN. € Vulvar, Cervical or endometrial Cancer € Radiotherapy € Smoking € Multiple sexual partner. € Early age first intercourse € DES in utero

labs in PCOS

↑LH, ↓FSH, .... LH:FSH ratio >3, (not always) - ↑testosterone, free testosteone -↓SHBG, - ↑ E2 and Estrone - normal to high DHEA-S (... but not at the very high level of androgen secreting tumor.... - above 13.5 = abnormal (Dr. Magee) 17-OH progesterone is normal, and can be used to differentiate from atypical CAH (must be morning, follicular) High liver function high cholesterol, triglycerides high insulin

Define ISD

□ Urodynamic finding o Leak point pressure < 60 cm H20 Or urethral closure pressure < 20 cm H20

Second line options for OAB

▪ Botulinum toxin injection Central and peripheral neurostimulation

Which 2 anticholinergic medications are the most M3 selective?

▪ Darifenacin (Enablex) Solifenacin (Vesicare)

contraindications to tocolysis

▪ IUFD ▪ Lethal fetal anomaly ▪ Nonreassuring fetal status ▪ Maternal hemorrhage with hemodynamic instability ▪ Chorioamnionitis

risks for hep B

▪ IV drug use ▪ STIs ▪ Multiple sex partners - high risk sex partners -male sex contact is higher risk ▪ House contacts ▪ institution/prison ▪ Health care workers ▪ International travellers - born in endemic areas

forceps check after application

▪ Posterior fontanelle should be located midway between sides of blades, with lambdoid sutures equidistant from forceps blades and one finger‐breadth above plane of shanks ▪ Sagittal suture must be perpendicular to plane of shanks ▪ Fenestration of blades should be barely felt and amount of fenestration felt on each side should be equal

4 anticholinergics can be given to elderly +/- cognitively impaired?

▪ Solifenacin (Vesicare) ▪ Trospium (Trosec) ▪ Tolterodine (Detrol) ▪ Darifenacin (Enablex) (STD mnemonic)

Which anticholinergics are best for cardiac patients

▪ Tolerodine (Detrol) Darifenacin (Enablex)

explain anencephaly

● "Your baby has a specific type of defect that is what we call a neural tube defect. In this particular scenario the baby's brain has not formed, nor the bones over the skull. It occurred very early in development. Unfortunately your baby won't be able to survive on the outside world. We might not ever find out why this happened this time, but there are things we can do to prevent it from happening again."

council, HIV transmission rates in pregnancy

● 25% overall ● 10% with monotherapy AZT antepartum, intrapartum & to babe for 6wks ● <1% with triple Rx, viral load <1000/undetectable ● If breastfeed: up to 10-20%.... likely lower if viral load is very low... but it is never zero, so breast feeding is not recommended

risks of untreated syphillis

● 30% chance of stillbirth ● 10% chance neonatal death ● 40% MR ● 60% congenital syphilis (though 2/3 will be asymptomatic at birth) ● 10-14% preterm labour ● 10-40% growth restriction ● Non immune hydrops

Risks for neural tube defects

● 95% have no family history Risk factors ● Family history - 1st or second degree relative ● Previous child with NTD (sibling to fetus) ● Preexisting NTD in either parent Diabetes meds- folic acid antagonists (methotrexate, septra, valproic acid) ● Obesity, BMI over 35

neural tube defect signs on ultrasound

● 99% with an open defect will have one or more of these findings: o small BPD o ventriculomagaly o scalloped frontal bones - lemon sign o effacement of cisterna magna - banana sign

Causes IUFD

● <20 weeks = spontaneous abortion ○ Chromosomal abnormalities (50%), congenital abnormalities exposure to teratogen ○ Uterine anomaly - maternal disease ○ Unexplained ● >20 weeks = stillbirth ○ Fetal (25-40%): chromosomal, congenital anomalies, non-immune hydrops, infections ○ Placental (25-35%): abruption, PPROM, FMH, cord accident, placental insufficiency, intrapartum asphyxia, previa, twin-twin transfusion, chorio ○ Maternal (5-10%): diabetes, hypertensive disorders, obesity, smoking, APLAS, thrombophilias, infections ○ Unexplained 15-35%

post op day 2 chest pain exam

● ABCs, VS ● General appearance, BMI ● Cardiac: S1/S2, murmurs, rhythm, pericardial rub, JVP ● Resp: air entry, crackles, adventitious sounds ● Abdominal: distension, HSM, C/S incision ● Vaginal exam: abnormal bleeding Legs: swelling , warmth, symmetry , edema

30yo G3P1 is referred to you for prenatal care. Antenatal blood work revealed Rh(D)-ve but antibody screen positive. 1. What else would you like to know on focused history?

● Age ● GPLTA ● Ethnicity ● Occupation ● PMH ● PSH: TAB, SAB, Ectopic Past Obstetrical History ● Rhogam received in previous pregnancies? ● previous testing? ● 1st trimester bleeding? ● T2: T2- u/s, : Antepartum hemorrhage, previa? Abruption? ● delivery hemorrhage, PPH ● Previous baby had jaundice? Phototherapy? Exchange transfusions? ● Same partner? pGyn ● SAB, TAB, ECTOPIC? PMHx ● previous blood transfusions?

post op chest pain hx

● Age , GPA, ethnicity ● PMHX o DVT\PE , thrombophilia, anemia o Cardiac : ▪ dyslipidemia, diabetes ,hypertension, o Respiratory : ▪ Asthma/COPD o Neoplasia ● Psurgical Hx : thorax, abdo ● meds : beta-blocker, OCP, anti-HTN, NSAID , asthma Rx ● Allergies ● Habits : smoking , alcohol , drugs ● Family Hx : DVT/PE/thrombophilia, M.I ● HPI : ● Surgical /anesthesia Hx ● type of surgery (laparoscopy/open) + indication , type of anesthesia ? ● blood loss intra-op\ transfusion ● Thromboprophylaxis ? (stocking , heparin UFH or LMWH) ● Post-op evolution in general ● SOB since when, acute, gradual ? Evolution? increase with inspiration ? ● Pleuritic chest pain, cough ● Calf pain ● CP, palpation, syncope , orthopnea, tachypnea, cough, hemoptysis ● Sputum ● Fever , signs of infection? ● Urinary sx , G-I sx , full review of systems ● Work up so far and tx started in ER?

anencephaly history

● Age, GTPAL ● Ethnic background of her and her partner Current pregnancy ● LMP, EDC, GA, dating by LMP or T1 U/S o Regular menses ● Antenatal blood work done - HepB, HIV, VDRL, Rubella ● Cramping, bleeding, N/V or hyperemesis, PPROM, fetal movements ● Spontaneous conception or ART ● Preconceptual folic acid or multivitamin ● Ultrasounds so far (before this one) ie. dating - results PObhx ● Year, GA at delivery, type of delivery, antenatal complications (bleeding, GDM, HTN), anomalies, chromosomal abnormalities, genetic diseases, birth weight, postpartum complications (PPH, depression) PGynehx ● Menstrual pattern, paps, STI's, D&C, surgery, contraception PMedhx ● Obesity ● Spina bifida ● Epilepsy ● Diabetes ● DVT/PE ● Anything else...? Meds ● Antiepileptics (phenytoin, carbamazepine, valproic acid, phenobarb etc) ● Folic acid ● Multivitamin Family history - her or her partner ● Anomalies - neural tube defects, cardiac ● Genetic diseases - Meckel-gruber, Roberts SC phocomelia ● Chromosomal abnormalities - T21, T13, T18 ● Developmental delay, mental retardation ● Neonatal deaths ● Consanguinity ● DVT/PE Allergies PSurghx Social ● Smoking alcohol, drugs, caffeine, occupational (heat)

diagnose neural tube defects

● All women should be offered screening ● Serum screening (MSS, IPS) or AFP alone (15-20 weeks) o Elevated in open NTD's only (>2.5 MOM) o Its primary use for screening of NTDs should be discontinued except in women with BMI >=35 or in an area where access to good quality US is limited (SOGC) ● Prenatal MRI can be considered if further detailed CNS assessment is required ● Amnio after 15 weeks for amniotic fluid AFP & acetylcholinesterase (dx open/closed NTD

headache/PIH workup

● Blood tests o CBC o Coags (INR, aPTT) o Fibrinogen o LDH o Albumin o LFTs (AST, ALT, GGT) o Bilirubin o Creat o Uric acid o Glucose o Blood smear (microangiopathy with RBC fragments) ● Urinalysis: protein content (dipstick, spot, 24 hour) - Urine PCR ● O2 sat Fetal: ● NST ● US o Presentation o Placenta o BPP/AFI o EFW o Dopplers: UA, MCA, DV

What are fetal and neonatal complications of shoulder dystocia?

● Brachial plexus injury ● Clavicle, humeral, rib fracture ● Asphyxia ● Metabolic acidosis ● HIE, CP ● Death

hepatitis workup

● CBC ● Serologies: VDRL + HIV, Hep C, chlamydia, gonorrhea, syphilis, BV, urine culture Full Hep B workup with all markers, ● Anti-HBc ● Anti-HBs ● HBeAg ● AST/ALT ● Alkaline phosphatase ● GGT ● Bilirubin ● Albumin ● Amylase, lipase ● Renal panel ● Coagulation profile (INR, PT, PTT) ● Glucose level ● Urine analysis: color, bilirubin, blood ● Stool analysis ● Abdominal US ● Liver biopsy In rare cases to distinguish from AFLP If positive, do Hep B viral load!!!!

anemia pregnancy workup

● CBC: Hb, Hct, Plts, red cell indices (MCV) ● Serum iron & ferritin level ● Electrophoresis (special ethnic group) ● Peripheral blood smear ● Renal panel ● LFTs ● TFTs ● Urine analysis ● Obs US: confirm #, viability & location

Turner syndrome POI treatment

● CEE 0.9-1.25 mg PO daily or estradiol 2 mg PO daily with cyclic progestin ● Or low dose contraceptive pill/patch ● Calcium 1200 mg/d ● Vitamin D 800 IU/d referral to internal medicine - cardiology - ENT - Nehpro

Turner syndrome complications

● CVS: bicuspid aortic valve, coarctation, dissection, aneurysm, HTN ● Endocrine: autoimmune thyroid dz, hypothyroidism, DM2, dyslipidemia ● Renal: horseshoe kidneys, collecting duct abnormalities ● GI: Crohn's, ulcerative colitis, liver dysfunction ● Skin: lymphedema, alopecia areata, vitiligo ● Bone: scoliosis, osteoporosis ● Hearing: conductive & sensorineural hearing loss ● Neuro deficit: impairment in non-verbal cognitive abilities, visual-spatial functions

risks of vacuum aspiration

● Cervical shock ● Perforation ● Injury to bladder/bowel ● Hemorrhage ● Hematoma (post abortal syndrome) ● Infection ● Incomplete tissue extraction ● Anesthesia risks ● Death

CVS vs amnio

● Chorionic villus sample: o 10-13 weeks o TC or TA approach o Risks: ▪ Pregnancy loss: TA 1-2% (twins 3.8%), TC 2-6% (twins 5.5%) ▪ Infection ▪ Limb reduction defect if done < 9 wks GA ▪ PVB (10-20% with TC) ▪ Mosaicism (1-2%) ▪ Cramping (TA) o Benefits: ▪ Done early ▪ Can do karyotype, FISH, microarray, whole genome sequencing ● Amniocentesis o US-guided TA technique o >= 15 weeks o Risks: ▪ Pregnancy loss 1/200 (1.7% vs. 0.7% without) ▪ Infection ▪ Rupture of membrane, talipes o Benefits: ▪ 99% accuracy ▪ Can do karyotype, FISH, microarray, whole genome sequencing, - AFP, AchE (both for neural tube)

TA counseling

● Counseling on the options available (should be free of bias) o Medical: ▪ 90% success at GA < 7 wks ▪ Can be done up to 8 wks ▪ MTX + misoprostol / misoprostol alone ▪ Must understand instructions, emotionally stable, willing to except surgical procedure if medical fails ▪ CI: sensitivity to meds, known coagulopathy, active liver/ renal disease, severe anemia, acute IBD o Surgical: ▪ Manual vacuum aspiration (<= 10 wks) ▪ Vacuum aspiration (<= 13 wks) ● Explain fully the nature of the procedure, type of anesthesia ● Safety of the procedure ● Potential immediate complications ● Potential long-term complications ● S/Es ● Ensure confidentiality ● Obtain consent

You are called from a community hospital in a land far far away by Dr. R (GP). Her pt is G1P0 at 35 wks GA. She came to the hospital with a H/A & epigastric pain.

● Current symptoms related to PET o H/A location/duration/severity o Visual changes o RUQ/epigastric pain duration/severity o Nausea/vomiting o Rapid weight gain/swelling o Jaundice ● Current pregnancy symptoms o Labour/CTX o ROM o PVB o FM PObH: ● Current pregnancy: o How were her dates confirmed o Prenatal care o Genetic screening/amnio o Anatomy US, other US o BP throughout pregnancy o Proteinuria in pregnancy PMH: HTN, DM PSH Meds Allergies

general life risks obesity

● DM2 ● HTN ● CAD ● Cardiomyopathy ● OSA ● Ischemic stroke ● GB dz ● Liver dz - NASH ● Osteoarthritis ● Subfertility ● Cancer - endometrium, colon, breast ● DVT ● Carpal tunnel syndrome ● Poor wound healing

CS risks with obesity

● Difficult/failed intubation or epidural ● Increased EBL (>1L) - difficult exposure - potentially increased injury ● Increased OR time ● Higher rate of wound infection & endometritis ● Higher chance of vertical incision - ● Increased risk of VTE

obesity risks in labor

● Difficulty with FHR monitoring (may need internal monitoring) ● Higher rate of IOL ● Dystocia ● Difficult epidural (failure) ● Higher chances of C/S ● Difficult intubation in case of emergency C/S

meds to treat PPCM

● Diuretics - first line ● Beta-blockers ● Digoxin ● Anticoagulants ● may benefit from bromocriptin in severe cardiomyopathy.

secondary amenorrhea investigations

● FSH (repeat on 2 occasions), LH, E2 ● Pregnancy test ● PRL ● Calcium phosphorus ● Glucose ● Adrenal antibodies to 21-hydroxylase ● TSH, T4 ● Rheumatoid antibodies ● Karyotype ● Fragile X mutation Imaging: ● Bone density for baseline ● TV-US ● +/- MRI head

can you give mom hep B prophylaxis ?

● Give HBIG (0.5 mL/kg IM) o Should be given within 14 days of sexual contact o Should be given within 1 month if blood or mucous membrane exposure ● Begin HB vaccine series (preferably within 24 hours of exposure) ● Prevents 75% of transmission

What is the most frequent cause of heritable POI that may lead secondary amenorrhea?

● Gonadal dysgenesis is the most frequent cause of POI: ▪ Individuals with gonadal dysgenesis can be divided into 2 groups based on whether the patient's karyotype is normal or abnormal o 70% abnormal karyotype: ▪ 50% XO (Turner syndrome) ▪ 50% 45X/46XX (mosaicism) ▪ Approximately 90% of individuals with gonadal dysgenesis due to loss of X genetic material never menstruate ▪ The remaining 10% have sufficient residual follicles to experience menses & rarely, may achieve pregnancy

physiologic anemia reasons

● Greater expansion of plasma volume (40-50%) compared to red cell mas Some use by the fetus possibly nutritional defiency inflammation

Categories of sexual dysfunction

● Hypoactive sexual desire disorder: o Deficient (or absent) sexual fantasies & desire for sexual activity, most common ● Female sexual arousal disorder: o Inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement ● Female orgasmic disorder: o Delay in, or absence of, orgasm following a normal sexual excitement phase ● Dyspareunia: o Genital pain that is associated with sexual intercourse ● Vaginismus: o Involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with penis, finger, tampon, or speculum is attempted

how does alloimmunization work ?

● IgG antibodies cross the placenta, bind to fetal RBCs and cause hemolysis ● Hemolytic anemia results when RBC lifespan falls < 70-90 days ● SEQUELAE o Significant anemia - mainly through hemolysis associated with RISE in hematopoetin o Hepatosplenomegaly (due to extramedullary hematapoeisis) o Hydrops: mechanism unknown. Theories: extreme Hb deficit, portal htn, hypoalbuminemia, cardiac dysfunction o Hyperbilirubinemia o Kernicterus (encephalopathy)

why is karyotype important in POI?

● In some cases of gonadal dysgenesis, chromosomal mosaicism may also include the presence of a Y chromosome, such as 45,X/46,XY ● The presence of a Y chromosome cannot be determined clinically as only a few patients will demonstrate signs of androgen excess ● A streak gonad should be removed if Y chromosomal material is present, as 25% will develop a malignant germ cell tumor

respiratory changes in pregnancy

● Increased VITAL CAPACITY (20% by 3rd trimester) ● Increased INSPIRATORY CAPACITY (20%) ● Decreased EXPIRATORY RESERVE VOLUME (from 1300 to 1100 ml) ● Increased TIDAL VOLUME (due to progesterone) ● Increased MINUTE VENTILATION (due to increased TV) ● Decreased RESIDUAL VOLUME (from 1500 cc to 1200cc) ● Decreased FRC (FUNCTIONAL RESIDUAL CAPACITY) - due to expanding uterus causing decrease in chest wall compliance ● Chest wall compliance is decrease by a third.

risks for hypothyroid in pregnancy

● Iodine deficiency ● Previous radioactive iodine treatment ● Presence of autoimmune disease ● Family history of autoimmune disease or thyroid disease ● DM1: incidence 5-8% of hypothyroidism, 25% risk of PP thyroid dysfunction

prevent perforation

● Knowing the position of the uterus (ultrasound - doing a proper pelvic exam ● Preoperative misoprostol (maybe) ● Dilate the cervix using gentle force or under US guidance (using finger as backstop) - ultrasound guidance ● Inserting the scope under direct vision

reasons for adolescents to delay treatement

● Lack of knowledge about the importance of prenatal care and lack of understanding of the consequences of its absence ● Victim of violence ● Desire to hide pregnancy ● Fear of potential apprehension of the baby ● Contemplation of abortion services ● Concerns about lack of privacy or judgmental attitudes ● Financial barriers ● Logistical barriers

severe mom risks of SLE

● Lupus nephritis (DPGN - diffuse prolierative glomerularnephritis) ● Lupus cerebritis (10-35%) ● Pericarditis ● Pulmonary HTN ● Severe HTN ● Stroke ● Thrombocytopenia ● Death

Risks of AMA

● Maternal o Miscarriage ▪ > 35 ~ 25% o Ectopic pregnancy (OR 4-8) o Multiple gestation o Medical (HTN, DM ~ 12%) o PET (5-10%) o IOL o C/S (~ 50%) o More maternal mortality ● Fetal o Chromosomal anomaly o Congenital malformations (see above) o LBW o PTB o IUGR o IUFD (RR 1.2-4.5) - term = 39 wks GA ● Placental o Placenta previa (0.25% vs. 0.03%) o Accrete o Abruptio

risks for sexual dysfunction

● Multifactorial ● Psychological o Depression o Anxiety o Conflict in the relationship o Fatigue o Stress ● Lack of privacy ● Prior sexual abuse ● Medications ● Physical o Endometriosis o Chronic medical conditions

what would you advise for anencephaly

● Organize termination of pregnancy (IOL) ● Offer social worker/ patient's leader of faith ● Asks patient how she is getting home, if alone, DO NOT DRIVE See in follow up

vulvar pain in pregnancy exam

● Overall appearance: nutritional status (thin?), pallor ● VS: BP, pulse, T, RR, 02-sat, pain scale ● Oral exam: look for herpetic vesicles ● H&N: rash, LN ● Skin exam: lesions/rashes ● CVS + chest exam ● Abdo exam: SFH, Doptone, HSM (for viral infections) ● Neuro: motor / sensory losses ● Inguinal LN ● Vaginal exam: o Speculum exam to look for lesions on the cervix o Examine the vulva, vagina for any lesions o Screen for other STIs

IBD / crohn / uc exam

● Overall appearance: nutritional status (thin?), pallor? ● Vital signs: BP, pulse, T, RR, 02-sat, pain scale (if applicable) ● HEENT: o Anemia: pallor o Oral lesions ● Thyroid - enlargement / nodules ● Lymphadenopathy ● Discoid rash ● CVS: S1/2, murmurs?, S3/4, rub? ● Resp: bilateral air entry? dullness? rub? (pulmonary involvement) ● Abdo: tenderness, HSM ● Extremities: pitting edema? rash? erythema nodosum/ pyoderma gangrenosum, arthritis, VTE ● Neuro: motor / sensory losses? DTRs ● Pelvis: perianal disease, fistulas

DDX of post op cesarean chest pain

● PET ● CHF (PPCM) ● MI ● PE - anxiety

adverse outcomes of adolescent pregnancy

● PTB ● LBW ● IUGR ● Stillbirth ● NICU admission ● Neonatal death ● Congenital anomalies PIH Nutritional deficiencies (ie, anemia) Postpartum: ● Contraception ● Breastfeeding ● PPD ● Parenting resources

indications for IV iron

● Patients that cannot tolerate PO iron ● Malabsorptive syndrome ● Severe iron deficiency anemia

late pregnancy risks of anencephaly

● Post-dates pregnancy ● Polyhydramnios

imitators of preeclampsia

● Pregnancy related: o HELLP o AFLP migraine TTP aHUS catastrophic antiphospholipid syndrome ● Not pregnancy related: o Secondary causes of HTN with end organ involvement e.g. renal dz, pheochromocytoma o Malignant HTN o DIC o Medications o Cavernous hemangiomas o Malignancy o Vasculitis & other systemic rheumatic conditions (SLE, scleroderma, etc.)

tests prior to hysteroscopy

● Pregnancy test, ● Pap test within 2 yrs ● Cervical cultures if clinically appropriate ● Endometrial sampling ● Assessment of uterine cavity for Müllerian anomalies or intracavitary pathology using TV-US, contrast infusion sonography, or diagnostic HSC

risks for preeclampsia

● Previous PET ● APS ● Preexisting HTN or booking dBP >= 90 ● Preexisting proteinuria or booking proteinuria ● Preexisting DM, GDM ● Maternal age >=40 ● Family hx of PET (mother, sister) ● Family hx of early onset CVD ● Multiple pregnancy ● Obesity ● nulliparity ● New partner ● Short duration of intercourse with current partner ● ART ● Inter pregnancy interval >= 10 yrs

1. What are the long-term complications of radiation therapy in a patient undergoing radiation for vaginal cancer?

● Rectovaginal and vesicovaginal fistulae ● Cystitis ● Proctitis ● Vaginal stenosis ● Rectal and vaginal strictures ● Premature ovarian insufficiency in women under the age of 40

what is risk of neural tube defect recurrence how to prevent

● Recurrence 3-5% if one affected fetus/child, 10% if two ● Folic acid reduces risk NTD's in a dose-related manner, both incidence and recurrence (level 1 evidence from RCTs) ● She may also want to lose weight to reduce her risk due to obesity ● FOLIC ACID!!!!!

post abortion abdo pain and temp DDX

● Retained tissue ● Hematometra ● Perforation ● Infection / endometritis

fetal risks of obesity

● SAB ● Increased congenital anomalies (and decreased US sensitivity) o Clefts o Omphalocele o Limb defects o Anorectal atresia o Diaphragmatic hernia o Heart defects o NTD o Hypospadia ● Macrosomia ● Stillbirth

chest pain investigations

● STAT investigations ● CBC, coags (INR\PTT\fibrinogen) ● Trops x 3 ● D-Dimers ● CXR ● ABG ● EKG ● Leg Doppler ● V\Q scan vs CT-Angio ● If known asthmatic consider PEFR

nec fasc presentaion

● Superficial incisional infection begins like any other postoperative infection with pain & erythema, the hallmark ● More specifically: o Subcutaneous & superficial fascial necrosis, manifested by excessive tissue edema in adjacent area o Blisters or bullae form in tissue that has become avascular & is discolored o There is usually a thin gray transudate o Tissue destruction is far more extensive than is evident by surface examination o The skin will slip over underlying tissue, & if incised, due to the lack of vascularity, there will be no bleeding o Severe systemic toxicity may develop

Q18. How do you prevent POF from chemo & RXT?

● Surgically reposition (oophoropexy), if possible, out of the anticipated RXT field prior to Rx ● Use of GnRH agonists or antagonists concurrent with or prior to therapy ● Oocyte & embryo cryopreservation

percent of hep B transmission

● T3: 80-90% ● T1: 10% ● HBsAg +: o With prophylaxis: 15% o Without: 1.5% o Overall: 2.9% ● HBeAg+: o Without Rx: 90% o With Rx: 10%

2. Define isoimmunization.

● The formation of maternal antibodies to fetal red blood cell (RBC) antigens is called RBC alloimmunization or "isoimmunization". It causes hemolytic disease of the newborn. ● Transplacental fetal to maternal hemorrhage is the most common cause of alloimmunization. Heterologous blood transfusion is 2nd most common cause ● Most common form is Rh-D, a woman's immunological response to paternally derived Rh(D)+ antigen inherited by the fetus

PID follow up

● Treat any sexual partner within the last 60 days ● Arrange for F/U within 72h ● Patients & their sex partners should abstain from sexual intercourse until therapy is completed (i.e., 7 days after a single-dose regimen or after completion of a 7-day regimen) ● Verify immunization status and vaccinate PRN (HPV, Hep B) ● Rule out other STIs

Hepatitis (elevated liver enzyme) exam

● VS, BMI ● General inspection: level of consciousness ● Skin and mucous membranes: any signs of IV drug abuse / jaundice / look at sclera (jaundice or pallor) / spider angioma / palmar erythema / nail changes (Muercke's nails) / clubbing / fetor hepaticus, bruises, wasting ● Cardiac/resp: Cruveilhier-Baumgarten murmur ● Abdominal exam: HSM, ascites, caput medusa, liver mass, SFH, Doptone ● MSK: Dupuytren's contractures / asterixis ● Lower limbs: signs of calf tenderness

reduce osteoporosis

● Weight-bearing exercise ● Quit smoking ● Reduce EtOH ● Calcium (1000-1500 mg/d) + vit D (800 IU/d) ● Bisphosphonates ● SERMS (Raloxifene)

epilepsy meds breastfeeding

● Yes, benefits outweigh risks for most drugs, less excreted in breastmilk (3-5% neonatal therapeutic level) ● If baby sleepy after feeds, encourage mother to feed baby before rather than right after meds taken

how does endo affect fertility ?

● o Endometrial receptivity o Interferes with embryogenesis or oocyte development o Tubal transport (chronic tubal inflammation) o Distortion of anatomy - preventing ovum pick up - ovarian reserve

contraindications to pregnancy SLE

●o Severe renal failure o Nephrotic syndrome o Severe HTN o Pulmonary HTN

chest pain post op DDX

⮚ Plural effusion ⮚ Pneumothorax ⮚ PE ⮚ Interstitial Edema ⮚ Atelectasis ⮚ Aspiration pneumonia ⮚ Pneumonia ⮚ ARDS ⮚ Bronchospasm ⮚ Cardiac: o MI o CHF

reasons to discontinue ECV

(1) NRFHR (2) excessive maternal discomfort (3) multiple failed attemps PPROM Bleding, apruption

types of ureteric injury

- Crush (clamp) - Kink (suture) -sharp ligation - thermal - devascularization

signs of uterine perforation

- Loss of resistance (sounding) - Visualization of the perforated site - Poor visualization of the cavity - Inability to distend the cavity - Absence of return flow - Intestinal loops

When would you favor abdominal suspension procedures over vaginal ?

- Surgeon's expertise -Prior failed prolapse repair procedure - Shorter vagina - Higher risk of recurrence: e.g. young woman with severe prolapse, lifestyle or medical condition with increased intra-abdominal pressure - Good overall health (minimal comorbidities)

PID inpatient criteria

- Surgical emergencies (e.g., appendicitis) cannot be excluded - Tubo-ovarian abscess - Pregnancy - Severe illness, nausea and vomiting, or oral temperature >38.5°C (101°F) - Unable to follow or tolerate an outpatient oral regimen - No clinical response to oral antimicrobial therapy

Fetal risks of CS:

- Transient mild TTN - Laceration

Stages of iron deficiency

1. Normal Hb/MCV- Storage depleted (low ferritin, increased TIBC) 2. Serum iron consumed (low serum iron, low transferrin % ) 3. Normocytic anemia 4. Microcytic, hypochromic anemia

high risk testing group for GDM

14-18 weeks Would still retest

ECV- when to offer?

36 weeks

when to remove cerclage

36-37 weeks (routine) labor PPROM (24 weeks on)

nuchal translucency what is it associated with ?

45-85mm 11-14 weeks o Chromosomal abnormalities - triploidy, trisomy 13, 21, Turner's (X0), sex chromosome abnormalities o Cardiac anomalies - rule out with echo if karyotype normal o Early TTTS o Diaphragmatic hernia o Single gene disorders - Noonan's

how would you define dystocia in first and second stage?

4cm in nulliparous 4-5 cm in a multip dystocia is: - <0.5cm per hour over 4 hours - NO change over 2 hours Note: ACOG definition is - no cervical change in active labor (6 cm) and adequate contractions for: - 4 hours on oxytocin - 6 hours without oxytocin second stage Greater than 1 hour of active pushing without descent of the presenting part.

chances of OASIS recurrence

5-10%

TOA treatment

<4cm resolve with antibiotics 85% of time >10cm will only resolve with Antibiotics 40% of time try to drain with IR guided therapy

hydrops history

A history should be taken, with particular attention to - ethnic background (ie, thalassemias) - family history of genetic diseases or congenital anomaly - consanguinity - recent maternal infections or exposures - maternal medications. ID · Age · GTPAL · Ethnicity of patient and her partner Current Pregnancy LMP, EDC, GA, dating by LMP or T1 U/S Regular menses Antenatal blood work done - Blood group and screen (? Rh negative, ? Rhogam administration), Prenatal Screening (IPS/other), routine serology, ? Parvovirus/TORCH infection testing, ? HBEL, ? GDM screen Indication for the current ultrasound - routine vs. secondary to concerns/symptoms Results of ultrasound: growth, AFV, biophysical profile and Dopplers as appropriate - other pertinent findings? Ultrasounds so far (before this one) ie. dating - results Singleton vs. twins Anatomic abnormalities - esp. structural such as cardiac anomalies and markers of aneuploidy, stigmata of TORCH infections Abruption · FM, CTX, ROM, PVB (+/- related trauma that could cause fetal/maternal hemorrhage) · Infections in the pregnancy - fevers, rash, arthralgias, etc. · Other complications in the pregnancy - HTN, hospitalizations, other Past OB History Year, GA, D&C for SA, type of delivery, antenatal/pp complications, BW, neonatal health, anomalies, genetic diseases, chromosomal abnormalities · In particular, any similar events in last pregnancy? Does she recall her blood type, did she get Rhogam if she was Rh negative? Did her baby need photo or exchange transfusions due to anemia? PMH · Any pertinent Hx · Thalassemia · Metabolic disease · Autoimmune disease (ie - SLE) · Congenital heart disease · Blood transfusion? PSH Meds · Indomethacin Allergies FH · Chromosomal anomalies, genetic disorders, syndromes, developmental delay · Metabolic diseases · Thalassemias · Congenital cardiac disease · Consanguinity SH · Occupation +/- exposures (ie - teacher, pediatrician), smoking, alcohol, illicit drugs, marital status/? Same partner as last pregnancy

What investigations would you like to order at this point in patient with 7cm mass in pregnancy?

A) Repeat ultrasound in ~ 4 wks · Size (? change) · Simple vs complex/septated · Solid component · Papillary excrescences/nodules · Vascularity with Doppler o Increased blood flow o Decreased resistance B) MRI · May aid at identifying origin · Provide more details about mass C) Tumour markers · Rarely helpful · Ca125 o Levels high in first trimester o Normalize until delivery (<35) o Peak again after delivery o Always <250-300 · AFP and BhCG elevated · LDH - no change in normal pregnancy, ↑ in HTN

eclampsia management

ABC protect airway left lateral O2 sat probe consider 100% o2 IV access EFM MgSO4

How can you reduce post date IOL

Accurate dating Stretch and sweep Nipple stimulation, intercourse

DDX for early OHSS

Alternative diagnoses such as- pelvic infection- intra-abdominal hemorrhage- ectopic pregnancy- appendicitis- complications of ovarian cysts such as (torsion or hemorrhage)

ovarian mass physical exam

Ans: Abdominal examination - assess for distension , ascites - mobility - rectovaginal examination to assess for mobility versus fixation.

List the factors that are important when counselling a women on initiation of the COC?

Include the following instructions: · Instructions on taking the COC , including when to start and importance of never having more than 7-day HFI · Non-contraceptive benefits · Potential side-effects and risks · Common myths and misconceptions · Risk and danger signs, including when and where to seek medical care · Instructions on what to do if pills are missed, including when to consider EC · Emphasizing dual protections (COC with condoms to protect against STIs and HIV)

risks of obesity post op

Infection (skin, endometritis) VTE preeclampsia

maternal toxoplasmosis symptoms

Asymptomatic (90%) he clinical presentation in pregnant women is not more severe than in non-pregnant women, and most often occurs as an influenza-like illness - fever - headache - malaise - LAD - rhinorrhea - joint pains - pneumonitis - myocarditis In contrast to infection in the immunocompetent host, toxoplasmosis can be a devastating infection in the immunosuppressed patient. In these individuals, dysfunction of the CNS is the most common manifestation of infection. Findings typically include - encephalitis, - meningitis - intracerebral abscess.

hep C mode of transmission

Blood most common - IV drug use - vertical - sexual - occupational exposure - previously, blood transfusions

Tumor markers

CA 125 LDH - dysgerminoma BhCG - choriocarcinoma AFP - yolk sac Inhibin B - Granulosa

investigate HMB in teens

CBC ferritin iron, iron studies Pt/PTT Von willebrand (antigen and assay) Platelet aggregation Bleeding time hCG pelvic ultrasound TSH

progestin only contraindications

CONTRAINDICATIONS Absolute contraindications include pregnancy (known or suspected), unexplained vaginal bleeding, and current diagnosis of breast cancer. Relative contraindications include severe cirrhosis, active viral hepatitis, and benign hepatic adenoma.

prevent subsequent OASIS

CS vacuum vs forceps mediolateral episiotomy with 60 degree angle Perineal massage warm compress Controlled pushing head control laying vs standing

Chorionicity vs zygosity

Chorionicity = Number of placentas Zygosity refers to the genetic make-up of a pregnancy. Multiple gestations can be monozygotic, dizygotic, trizygotic, etc.... Amnionicity- number of yolk sacs DCDA twins- can be either monozygotic or dizygotic MCDA or MCMA- always monozygotic

side effects of vaccines in pregnancy

Common: local soreness, , erythema/swelling, malaise/fever, Rare: anaphylaxis, Guillan-Barre

high risk antibodies

D c C e E kell Duffy Kidd

what can increase rates of SVD

Dedicated maternal support ***Delayed pushing IA as opposed to EFM Longer second stage Manual rotation

vulvar pain exam

Directed Physical Exam: • Vulvar inspection - masses, lesions, erythema, • Q-tip test - test for point tenderness, examination of the vestibule and gentle touch under the urethra o What may find: reddened, inflamed vestibule with positive tenderness of Q-tip test all way around introitus o No lesions or other abnormalities o Do swabs (vestibule, vagina and cervix, may or may not be able to do pap if can't get speculum in) • Bimanual or single digit exam - trigger points inside vagina, vaginismus, tension of levator ani, bulbocavernosus • Speculum if you can and then do pap

position patient for laparoscopy

Ensure good size table large stirrups arms tucked- possible extenders good padding h

ddx for seizures

Epilepsy - diagnosis of exclusion Eclampsia TTP Ischemic/hemorrhagic stroke Drug, alcohol withdrawal AVM Brain tumor Metabolic abnormalities - hypoglycemia, hypocalcemia, hyponatremia Infections

Contraindications to HRT HRT contraindications

Estrogen Undiagnosed vaginal bleeding Acute liver disease Active thromboembolic disease Relative (caution): cerebrovascular disease, coronary artery disease, Breast cancer, past VTE, elevated lipids, Progesterone Known or suspected breast cancer Undiagnosed vaginal bleeding Pregnancy

combo chemo for GTN

Etoposide, MTX, ActD, cyclophosphamide, and vincristine (EMA-CO), The EMA-CO regimen is well tolerated, and treatment seldom is suspended because of toxicity. The EMA-CO regimen is the preferred primary treatment inpatients with metastasis and a high-risk prognostic score >6. EMA-EP Patients resistant to EMA-CO can be treated successfully by substituting cyclophosphamide & vincristine with etoposide + cisplatin on day 8 (EMA-EP). EMA-EP induced remission alone or with surgery in 16 (76%) of 21 patients who were resistant to EMA-CO

risks for PMS

Family Hx previous PMS Anxiety, other mood disorders

OB history

GTPAL Happy ? planned, unplanned ? any previous complications ? LMP ? Ultrasounds ? Serology ? (Hep B, C, HIV, syphillis, rubella, GC, urine culture, varicella) screening ?

weight gain pregnancy risk

GWG is associated with increased risks of gestational hypertension, preeclampsia and diabetes, fetal overgrowth, operative delivery, and postpartum weight retention. InadequateGWG is associated with fetal growth restriction

assess for hemorrhagic shock physical exam

General inspection, is patient alert, oriented Vitals, HR, RR, labored breathing Mucus membranes, cap refill early shock patient is alert, anxious normal or slightly warm low grade tachycardia normotensive or slight hypo normal urine late shock patient confused cold clammy very hypotensive, tachycardic

Monopolar hysteroscopy medium

Glycine (electrolyte poor) 750 to 1000 ml finish up 1.5L hard stop Causes: Hyponatremia hyper ammonia pulmonary edema cerebral edema

causes of hyperthyroid in pregnancy

Graves' disease Transient gestational hyperthyroidism subacute thyroiditis GTD Toxic multinodular goitre Single toxic adenoma iatrogenic- meds

ectopic DDX

Gyne -adnexal - Mittelschmerz - ruptured ovarian cyst - hemorrhage into ovarian cyst/neoplasm - ovarian torsion - uterine - degenerating fibroid - torsion of pedunculated fibroid - pyometra/hematometra - infectious - acute PID - endometritis Non-Gyne - GU - UTI/cystitis - renal colic - GI - appy - mesenteric adenitis - diverticulitis - IBD

Vaccines contraindicated in pregnancy

HPV MMR Varicella Live attenuated influenza smallpox

Peripartum cardiomyopathy

Heart failure with no identifiable cause can develop between last month of pregnancy to 5 months postpartum EF < 45% During the evaluation, other causes of heartfailure must be ruled out, such as - hypertension - coronary artery disease - valvular disease -history of cardiotoxic chemotherapy or thoracic radiotherapy, - lupus, - thyrotoxicosis. - infections (viral, HIV, lyme) Toxic (alcohol, cocaine) Chronic medical conditions (renal disease, scaroid, lupus)

vaccines in certain circumstances in pregnancy

Hep A Hep B pneumococcal meningococcal

emergency contraception options

Hormonal Yuzpe Plan B Ulipristal acetate Copper IUD

What two disorders increase dopamine levels and thus change GnRH pulsatility leading to secondary amenorrhea?

Hypothyroid Hyper-prolactin

Lichen sclerosus differentials

LS vitiligo vulvar atrophy Lichen planus (more purple, but the whickam striae) VAIN vulvar cancer

type of twins

Identical twins (monozygotic ) Fraternal twins (dizygotic) DCDA can be mono or di zygotic MCDA or MCMA is always mono-zygotic

Hyperthyroid history

Thyroid symptoms/disease During this pregnancy or ever before? If so, when? Nervousness, palpitations, tremor, weight loss, frequent stools, heat intolerance, hair or skin changes, sweating, insomnia Fatigue, cold intolerance, weight gain, constipation Diagnosed before? Grave's disease? Thyroid nodules Goiter Seen an endocrinologist Treatments before and when Medications, surgery, radioablation Side-effects from meds Last time her thyroid function tests were done antithyroid antibody levels

adnexal mass imaging

Ultrasound CT abdo/pelvis +/- MRI

what are causes of death in OHSS ?

VTE ARDS hepato-renal syndrome

Menopause hormone therapy family hx

VTE (DVT or PE) CAD or MI Stroke Cancer Liver disease Endometriosis Fibroids Gallbladder disease or jaundice Hepatic hemangioma Fluid retention and renal disease Hypothyroidism Dementia Osteoporosis and fracture

types of cerclage

Vaginal (McDonald, Shirodkar ) abdominal (laparoscopic or open)

complications of pessary

Vaginal discharge (the most common) Odor Vaginal infection Erosion /ulcer Failed fitting / expulsion Discomfort If neglected: fistula formation

manage uterine perforation

Vitals IV fluids

manage mixed urinary incontience

What is the initial management of mixed urinary incontinence? · SUI: kegels, meds, pessary, PFP, surgery (but first w/u fistula), expectant /5 · OAB: kegels, meds, PFP, BT, decrease caffeine /5

OHSS history

When did symptoms start?....................................................... ___/1 Did she have an embryo transfer?.................................... ......... ___/1 How many embryos were transferred? .........................................___/1 Is she taking any medications? .................................................. ___/1 For symptom relief As part of fertility tx (HCG? Cabergoline?) What is her oral intake? Diet? Is she on a special diet (high salt)? Drinking lots of fluids? ... ___/1 Increased abdominal girth / bloating?.......................................... ___/1 Any pelvic pain? .................................................................. ___/1 Any nausea or vomiting?......................................................... ___/1 Any change in bladder function? Change in urine output/concentration?.___/1 Any change in bowel function? Flatus? Any s/sx of bowel obstruction?. ___/1 Any fever? Cough (productive?), shortness of breath? Can she lie flat?.. ___/1 Any calf tenderness? Swelling? Any chest pain? ............................. ___/1 Infertility History: What treatment cycle # is this for her? What other fertility treatment has she received? ................................................................................... ___/1 What were her previous outcomes? ............................................___/1 Any previous complications from treatments / previous OHSS?........... ___/1 Details of previous complications/hospital admissions?............... ___/1 What is the cause of her infertility? Does she have PCOS?................. ___/1 What dose of medication was she on in this cycle and how does it compare to previous?.............................. ........................... ......... ___/1 PM/SHx? .......................................................................... ___/1 Allergies ........................................................................... ___/1 Habits/social ...................................................................... ___/1

primary syphilis manifestations in mom

When present, the initial manifestation of the immune reaction is the primary chancre, which appears approximately three weeks after infection. Without treatment, the chancre resolves spontaneously in 4-6 weeks. The chancre may occur on the cervix, vagina, or vulva, so a thorough physical exam is necessary when syphilis is diagnosed...... note, up to 40% have multiple chancres ~25% of these are cleared

post maturity syndrome

Wrinkled, patchy, peeling skin Long thin body ...... Open-eyed, unusually alert Old, worried-looking ...... Long nails

Z score T score Osteopenia Osteoporosis

Z-score: number of SD's in bone density from mean for age and sex T-score: number of SD's from mean for 30 year old adult the same sex as the patient Osteopenia: between -1 to -2.5 T-score Osteoporosis: -2.5 T-score or lower Severe osteoporosis: plus a fragility fracture

neonatal lupus

a rare condition acquired from the maternal autoantibodies which can affect the skin, heart, and blood of the fetus & newborn; associated w/ a rash that appears w/in several weeks of life & may persist for about six months before disappearing Cutaneous lupus • Red, scaly plaques on scalp/face • Hematologic lupus • Anemia, leukopenia, thromobocytopenia • Congenital heart block Resolves in 6 months

who heart disease pregnancy

a system for assessing maternal risk in the setting of heart disease. This has since been modified into risk assessment principles and subsequent applications/recommendations WHO class I and II women tolerate pregnancy with no to mildly increased risk for cardiac events while women in class III have significantly elevated risk of morbidity. Women in class IV are strongly encouraged to avoid pregnancy because of the prohibitive increase in morbidity and mortality. Pregnant women in class III or IV should be followed very closely by a multidisciplinary team, including visits to a cardiovascular specialist every 1 to 2 months

types of vaginal cancers

a. Primary Vaginal Cancer. Rare only in 1-2%. o Squamous cell (80%) o Adenocarcinoma. o Melanoma. Second most common. 5% of all. b. Secondary (metastatic) Vaginal cancer. 90%. Most common related cancers are cervix vulva and endometrial.

reasons for emergency CS

abnormal fetal surveillance in labour (71%), abnormal fetal surveillance antepartum (10%), abruption (6.3%), suspected uterine rupture (4.8%), and cord prolapse (8%). Urgent Caesarean births include nonprogressive labour (54%) or atypical fetal surveillance (36%).

amenorrhea

absence of menstruation Primary amenorrhea- before menarche Secondary amenorrhea - a) absence of menstruation for 3 months in a female who previously had regular menstrual cycles OR b) 6 months in a female with previously irregular cycles

what infections cause microcephaly

all TORCH CMV most comon Zika

34 year-old G1P0 at 40 weeks'. 4cm/ 60%/ -2 at 01h00. Cervix unchanged at 0730. What would you want to know on hx ?

all about pregnancy, Dating, aneuploidy screening morph scan (anomalies? ) GDM GBS EFW ? position ? complicatios? Spontaneous or induced? if so, why ? Leakage of fluid? color? amount? contraction pattern? oxytocin? fetal heart?

indications for Mg for neuroprotection

avtive labor, or expect imminent delivery in 24 hours planned delivery in 24 hours GA < 34 weeks

investigate ovulatory dysfunction

bHCG Day 3 : LH, FSH, E2, TSH, prolactin AFC or AMH HbA1C triglycerides, cholesterol Ultrasound (ashermans) Day 21 Mid luteal progesterone Consider (if indicated) 17-OHP, cortisol DHEA-S free test, androstendione 24 hour cortisol

diagnose sickle cell

can diagnose - Preimplantation (ie, IVF and PGD) Prenatal CVS or amnio Postnatal (cord blood or blood from baby)

what med should be used for PPH at cesarean

carbetocin 100mcg less need for additional uterotonics

types of sweling

chigon cephalohematoma Subgaleal hemorrhage

long term consequences of hep B

cirrhosis hepatocellular carcinoma

what populations is steroid administration uncertain benefit ?

clinical scenarios where there is uncertainty with regard to the benefits and risks of antenatal corticosteroid therapy include: - women at high risk of preterm birth at periviable birth - women at risk of late preterm gestations -women requiring elective pre-labour Caesarean delivery at term gestations - women at high risk of preterm birth who have received a first course of antenatal corticosteroid therapy more than 7 days previously

prepare surgically for accreta

consider stents midline laparotomy classic incision Internal iliac ligation Regional anaesthesia may be safer than general anaesthesia as it is associated with reduced blood loss and is preferred by patients and their partners (II-2A). A massive transfusion protocol should be in place to respond to significant blood loss (III-B).

DDX for anterior vaginal wall mass

cystocele urethral diverticulum gardner duct cyst Malignancy

failure rates, forceps vs vacuum

forceps, 10% Vacuum, 15%

risks of laceration

macrosomia malposition instruments midline epis uterine rupture extensions at CS

risks for atypia

older age Menstrual factors (early menarche, late menopause, nulliparity, anovulatory cycles, PCOS ) Obsesity Diabetes Genetic (lynch syndrome, BRCA ) Liver disease Tamoxifen

Cowden syndrome What gene ?

presence of hamartomatous polyps in the GI tract associated with the PTEN gene; CS is characterized by a high risk of both benign and cancerous tumors of the - breast -thyroid - endometrium (uterus) - colorectal - kidney - skin (melanoma). Other key features of CS are skin changes, such as trichilemmomas (skin tags) and papillomatous papules, and macrocephaly, meaning larger than average head size.b

risks for accreta

previous accreta family hx of accreta advancing age Cesareans Multiparity cesarean closure technique D&C's Asherman's Submucosal fibroids Placenta previa

what are future consequences of PID

recurrent PID pelvic pain ectopic pregnancy infertility

alcohol withdrawal

• IV hydration • Thiamine • BZDs (diazepam, use lorazepam in labor)

risks of hysteroscopy

● Anesthesia complications ● Uterine perforation 1-9% ● Adjacent organs injury ● Bleeding (most common) ● Complication from the distension media (hyponatremia, volume overload, etc.) ● Air embolism ● Pelvic infection

menopause workup

● CBC ● TSH, PRL ● LH, FSH ● Fasting glucose, lipids ● LFT's ● Endometrial Bx ● DEXA (BMD) ● Mammogram

causes of failure of iron to work

● Non-compliance ● Incorrect diagnosis ● Malabsorption ● Ongoing blood loss

what should you screen an adolescent for in pregnancy ?

● Smoking, substance/alcohol abuse ● IPV ● Mood disorder/depression ● Nutritional deficiencies

Causes of fetal tachycardia

Maternal causes: - fever - tachycardia - anemia - dehydration -anxiety - hyperthyrodism - drugs (ie, atropine, caffeine) Fetal causes: - infection - arrhythmia - cardiac failure or anomalies - distress (hyoxemia) -anemia

How to optimize for acreta surgery

Maternal hemoglobin maternal serologies (Hep B/C, HIV) Pap test prior surgeries anesthesia consult NICU consult Advise to avoid travel far away from the site

hormone therapy doses menopause

Mirena IUD + estrogen transdermal estradiol 0.025 mg twice weekly or oral estradiol 0.5 mg daily. - Premarin) 0.625 mg daily Progestin Provera- 2.5 mg orally daily prometrium 200mg PO daily

fetal risks of SLE

Miscarriage higher risk of anomalies IUGR • LBW • PTD (21%) • IUFD - T2 and T3 • Congenital heart block if Anti SSA or SSB + Preeclampsia risks Neonatal lupus risks

Determine zygosity

Monochorionic are always monozygotic if the gender is different they are dizygotic DNA/blood testing after birth NIPT Invasive testing (CVS,amnio)

aneuploidy screening for twins

NIPT - Panorama NT + maternal age NT + serum markers in first trimester Second-trimester serum screening using maternal serum levels of α-fetoprotein, hCG, unconjugated estriol, and inhibin A Second trimester screening + NT Invasive testing- CVS or amnio

treat endometriotis pain

Non pharmacologic - NSAIDs , Tylenol - preferably avoid opioids, but maybe PRN - heating pads Pharmacologic - menstrual supression COCP Progestin only oral (norlutate, visane ) depo provera Mirena IUD Nexplanon Lupron with add-back GnRH Antagolost (elagolix) Danazol Ancillary - SNRI - TCA, Gabapentin Other pelvic pain - pelvic physio - CBT

labor analgesia options

Non- Pharmacological Transcutaneous electrical nerve stimulation Temperature modulation: hot or cold packs, water immersion Hypnosis Massage Acupuncture Aromatherapy Pharmacological Regional Epidural Spinal Pudendal block Paracervical block Systematic Inhaled Nitrous oxide (N2O) Volatile Anaesthetics: Isoflurane, Halothane Balanced Anaesthesia (Combination of nitrous oxide with halogenated agents) Parenteral Meperidine (Pethidine) Promethazine Nalbuphine Fentanyl Morphine Butorphanol (stadol) *less neonatal resp depression than mepridine

contraindications to cerclage

Nonviable fetus major congenital anomalies, chorioamnionitis, ruptured membranes placental abruption placenta previa active labor

should you remove the uterus with BRCA?

Not needed to reduce risk of uterine cancer Possible to do, but not technically needed Can increase risks of surgery, OR time, blood loss.

what increases risks for being post dates

Nulliparity Increased BMI AMA unfavorable cervix Anencephaly Placental sulphatase deficiency Previous postdates Adrenal hypoplasia

when do OHSS symptoms occur?

OHSS symptoms may begin as soon as 24 hours after hCG administrationmost severe 7 to 10 days after hCG, usually associated with the rise of endogenous hCG from an early pregnancy

higher risks to obese patients with laparoscopy

Obese patients are prone to nerve injuries pressure sores, especially during long cases; bleeding, infection, VTE, convert to open

risks for SSI

Obesity intra-op blood loss Diabetes immunosuppression Smoking long surgery

1. In which patients with recurrent urinary incontinence after surgical intervention could urodynamic studies be omitted?

Only 1 prior surgery for UI Symptoms of pure SUI No symptoms of OAB No symptoms of voiding dysfunction Hypermobile urethra PVR < 100 mL Normal urinalysis

Treat Neonatal abstinence syndrome

Opiate treatment and weaning.................................................... ___/1 Lengthy hospitalization (usually one week minimum) ...................... ___/1

acute abdominal pain HX

Outline of pain pattern and associated GI and GU (SOCRATES) N/V Bowel symptoms Bladder symptoms Menstrual history - cycle pattern and LMP: Sexual activity history: ___ 1 Past surgical history: ___ 1 Past medical history: ___ 1 Rx: Tylenol XS ___ 1 Allergies: NKDA

what cancers are lower in COCP

Ovarian Endometrial Colorectal

name 3 options for testing in parents with balanced translocation

PGD CVS Amnio

Besides post treatment HPV testing , what are other indications for HPV typing ?

Post HPV resolution testing -cotesting in >30 yo -women > 30 with SIL -postmenopausal pt with ASCUS /LGSIL on pap -work up of AGC

deliver previa and LLP Deliver PAS

Previa: week 36 or 37 (earlier if risk factors) LLP: week 37 or 38 (earlier if risk factors) PAS: 34-36 weeks

prevent OHSS

Primary- identify risk factors in advance, and choose appropriate cycle (ie, use orals over gonadotropins if possible) Secondary- recognize patients with hyper-responsiveness to gonadotropins and intervene to reduce risks, but salvage cycle

tubal factor infertility treatment

Proximal - hysteroscopic canulation - IVF Midtubal - surgical reanastomosis - IVF Distal - salpingostomy - if bilateral hydrosalpinx salpingectomy and IVF

VTE risk factors

Reversible Obesity: most common reversible Cigarette smoking Hypertension Immobilization Pregnancy BCP Postmenopausal HRT Non-reversible Surgery Trauma Cancer (look for it lung, GI, breast, uterus) Thrombophilias Medical conditions: pneumonia, CHF Aft

risks of bacteriuria

Risks of bacteriuria: - preterm birth (with complications of prematurity) - low birth weight (OR ~1.5 vs without) - pyelo (OR 20-30x vs non-pregnant)..... - ARDS - urosepsis - death

DDX for maternal fever and rash

Rubella Measles German Measles Parvo Scarlet fever -

neonatal rubella transmission by GA

Rubella transmission rates -In the first trimester, fetal infection rates as high as 81 percent have been observed - dropping to 25 percent in the late second trimester - increasing again in the third trimester from 35 percent at 27 to 30 weeks - nearly 100 percent for fetuses exposed beyond 36 weeks The risk of major fetal damage varies with the time of maternal infection: - 80-90% in the first three months of pregnancy - 10% in the fourth month - 6% in the fifth month, often as isolated hearing impairment. There is minimal risk in late gestation, only IUGR . non-pregnant females should be vaccinated with the live MMR vaccine prior to pregnancy.

obesity cs risk

SSI blood loss anesthesia risk

treatment options for menopause depression

SSRI SNRI psychotherapy like CBT

latent stress incontinence

SUI that is unmasked when prolapse reduced

bipolar hysteroscopy medium

Saline (electrolyte rich) Finish at 2L, stop at 2.5L Causes fluid overload symptoms (pulmonary edema, cardiac strain) but not the cerebral edema or hyponatremia

sexual history

Sexual history • Sexually active? • Relationship status • Age at first intercourse • Multiple partners, • Sexually active w/ men/women/both • Dyspareunia • Sexual dysfunction • Sexual abuse, harassment • Condom use • Future pregnancy desires

palmer point contraindications

Significant hepatosplenomegaly, portal hypertension, previous splenic or gastric surgery

causes of preterm birth

Spontaneous PTB, PPROM, iatrogenic indicated for maternal reasons and fetal reasons cholestasis Cervical insufficiency Systemic infection genital infection Abruption HTN HPV h

Crohn's meds and pregnancy

Stop methotrexate ● Sulfasalazine & azathioprine safe in pregnancy - ensure compliance ● Should start folic acid now ● Calcium supplements

categories of prolapse pessaries

Support (ring +/- diaphragm, Shaatz) Space-occupying (cube, inflatoball, donut) Combination (Gellhorn)

What are indications for paracentesis/culdocentesis?

Symptomatic SOB Tense/painful ascites Oliguria/anuria Renal failure with rising creatinine/decreased CrCl Hemoconcentration not responding to medical Tx

name AIDS defining illness

TB Kaposi Sarcoma Burket lymphoma candida pneumocystitis pneuomona

medical treatment options for IC

TCAs (amitriptyline) Hydroxyzine (or other anti-histamine) Bladder instillations ● DMSO (anti-inflammatory) ● Bicarb ● Heparin (GAG) ● Lidocaine Refractory: -Cystoscopy under anesthesia with hydrodistention -Treatment of Hunner's lesions if found (fulguration, laser) -Neuromodulation -Intradetrusor botox Last resort: diversion +/- cystectomy

what hormones are involved in prolactin release

TRH - stimulated release Dopamine- inhibits

risks specific to MCDA and MCMA

TTTS TAPS TRAP S-IGR Neonatal brain injury if death of one cord entanglement conjoined

toxoplasmosis transmission

The 3 main routes of transmission are - ingestion of cysts raw or undercooked meats - exposure to oocyst-infected cat feces - vertical transmission. ingestion of cysts (from food, water, hands, or insects) from uncooked/undercooked meat of infected animals (e.g., lamb, pork) - contact with oocysts from infected cats (who get it from infected mice, etc.) or contaminated soil. Overall, the vertical transmission rate ranges from approximately 20% to 50%. Of congenitally infected fetuses who are PCR positive by amniocentesis, 74% to 81% manifest only subclinical infection (only serologically positive) whereas 19% to 26% have fetal/childhood illness even if they received treatment Infection is most serious in first trimester