Flashcards
GYNECOLOGY & OBSTETRICS CASES
Cards in this deck (33)
- 1—1-Patient with EP emergency case
2- patient with EP non emergency case
D iagnosis
Approach a woman of reproductive age presenting with abdominal pain as a
ruptured ectopic pregnancy until proven otherwise.
n Look for a pregnancy test and a transvaginal ultrasound showing an
empty uterus (see Figure 2.11-8).
n Confirm with a serial hCG without appropriate hCG doubling.
t rEatmEnt
n Medical treatment (methotrexate) is sufficient for small, unruptured tubal
pregnancies.
n Surgical options include salpingectomy or salpingostomy with evacuation
(laparoscopy vs. laparotomy).
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The classic triad of ectopic
pregnancy PAVe s the way for
diagnosis:
P ain (abdominal)
A menorrhea
V aginal bleeding
e ctopic pregnancy - 2—1-Patient with PP emergency case
2- patient with PPnon emergency case
- 3—1-Patient with PAemergency case
2- patient with PA non emergency case
- 4—1-Patient with Vasa Previa emergency case
2- patient with Vasa Previa non emergency case
- 5—Vagina bleeding & anemia in 90%
hyperemesis gravidarum(nausea and vomiting,preclampsia,
uterine enlargement (large for date
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iorn deficency +folic acid + vit A
Maternal blood group B/AB
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Snow Storm apperance
Mangement Molar Pregnacy according cases
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N. :- ULS:- snowstrom/follow up=BHCG/ D&C :CLUSTER-OF-GRAPES ,/CXR:- LUNG METASTASIS IF/ /choriocarsoma SIGNS /more than period of amenorea vs /pain specific /dullache / utstreach =acute abd/ If emergency =Resusciation /section and evacuation /If
bleeding is RH- give ANTI D
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Termination of pregnancy by dilatation and curretage
Then follow up with weekly hcg to monitor for residual disease
It should be normal in less than 6 weeks
If it stays high, u should do hysterectomy to remove residual disease and do chest xray to look for metastasis
And give chemotherapy such as methotre
- 6—pre rupture of membrane PROM
- 7—Hyperemesis-Gravidarum
The first step in the diagnosis of
hyperemesis gravidarum is to rule out
molar pregnancy with ultrasound +/−
β-hCG
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If “morning sickness” persists after
the first trimester, think hyperemesis
gravidarum
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t rEatmEnt
n Administer vitamin B 6 .
n Doxylamine (an antihistamine) PO.
n Promethazine or dimenhydrinate PO/PR.
n If severe: Metoclopramide, ondansetron, prochlorperazine, or prometha-
zine IM/PO.
n If dehydrated: IV fluids, IV nutritional supplementation, and dimenhydri-
nate IV.
- 8—diabetes in pregnancy
D iagnosis
n Conduct a 1-hour 50-g glucose challenge test:
n Venous plasma glucose is measured 1 hour later.
n Performed at 24–28 weeks.
n Values ≥ 140 mg/dL are considered abnormal.
n Confirm with an oral 3-hour (100-g) glucose tolerance test showing any
2 of the following:
n Fasting: > 95 mg/dL.
n One hour: > 180 mg/dL.
n Two hours: > 155 mg/dL.
n Three hours: > 140 mg/dL.
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Keys to the management of gestational
diabetes: (1) the ADA diet; (2) insulin if
needed; (3) ultrasound for fetal growth;
and (4) NST beginning at 30–32 weeks
if GDMA2 (requiring insulin or an oral
hypoglycemic)
- 9—Pregestational Diabetes and Pregnancy
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t rEatmEnt
n Mother:
n Renal, ophthalmologic, neural tube, and cardiac evaluation to assess
for end-organ damage.
n Strict glucose control (diet, exercise, insulin therapy, and frequent self-
monitoring) to minimize fetal defects.
n Fasting morning: ≤ 90 mg/dL.
n Two-hour postprandial: < 120 mg/dL.
n Fetus:
n 18–20 weeks:
n Ultrasound to determine fetal age and growth.
n Evaluate for cardiac anomalies and polyhydramnios.
n Quad screen to screen for developmental anomalies.
n 32–34 weeks:
n Close fetal surveillance (eg, NST, CST, BPP).
n Admit if maternal DM has been poorly controlled or fetal param-
eters are a concern.
n Serial ultrasounds for fetal growth.
n Delivery and postpartum:
n Maintain normoglycemia (80–100 mg/dL) during labor with an IV in-
sulin drip and hourly glucose measurements.
n Consider early delivery in the setting of poor maternal glucose control,
preeclampsia, macrosomia, or evidence of fetal lung maturity.
n Cesarean delivery should be considered in the setting of an estimated
fetal weight (EFW) > 4500 g.
n En
- 10—gestational and chronic hypertension
t rEatmEnt
n Monitor BP closely.
n Treat with appropriate antihypertensives (eg, methyldopa, labetalol, nifed-ipine).
n Do not give ACEIs or diuretics.
n ACEIs are known to lead to uterine ischemia.
n Diuretics can aggravate low plasma volume to the point of uterine is-
chemia.
- 11—Pre-eclampsia and eclampsia
The classic triad of preeclampsia—
it’s not just H y Pe
H ypertension
P roteinuria
e dema
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HELLP syndrome:
H emolysis
e levated L FTs
L ow P latelets
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t rEatmEnt
The only cure for preeclampsia/eclampsia is delivery of the fetus.
n Preeclampsia:
n Close to term or worsening preeclampsia: Induce delivery with IV
oxytocin, prostaglandin, or amniotomy.
n Far from term: Treat with modified bed rest and expectant management.
n Prevent seizures with a continuous magnesium sulfate drip.
n Watch for signs of magnesium toxicity (loss of DTRs, respiratory pa-
ralysis, coma).
n Continue seizure prophylaxis for 24 hours postpartum.
n Treat magnesium toxicity with IV calcium gluconate.
n Severe preeclampsia:
n Control BP with labetalol and/or hydralazine (goal < 160/110 mm Hg
with a diastolic BP of 90–100 mm Hg to maintain fetal blood flow).
n Continuous magnesium sulfate drip.
n Deliver by induction or C-section when the mother is stable.
n Eclampsia:
n ABCs with supplemental O 2 .
n Seizure control/prophylaxis with magnesium.
- 12—Antepartum haemorrhage
n Any bleeding that occurs after 20 weeks’ gestation.
n Complicates 3–5% of pregnancies.
n The most common causes are placental abruption and placenta previa
(see Table 2.11-14 and Figure 2.11-7).
n Other causes include other forms of abnormal placentation (eg, placenta
accreta), ruptured uterus, genital tract lesions, and trauma.
- 13—Obstetric Complications of Pregnancy
- 14—intrauterine growth restriction (iugr)
D iagnosis
n Confirm serial fundal height measurements with ultrasound.
n Ultrasound the fetus for EFW.
t rEatmEnt
n Explore the underlying etiology and correct if possible.
n If the patient is near due date, administer steroids (eg, betamethasone) to
accelerate fetal lung maturity; requires 48 hours prior to delivery.
n Perform fetal monitoring with NST, CST, BPP, and umbilical artery Dop-
pler velocimetry.
n A nonreassuring status near term may prompt delivery.
- 15—n Defined as a birth weight > 95th percentile. A common sequela of gesta-
tional diabetes.
n Dx: Weigh the newborn at birth (prenatal diagnosis is imprecise).
n Tx: Planned cesarean delivery may be considered for an EFW > 5000 g in
women without diabetes and for an EFW > 4500 g in women with diabe-
tes.
n Cx: ↑ risk of shoulder dystocia (leading to brachial plexus injury and Erb-
Duchenne palsy) as birth weight ↑.
- 16—n An AFI > 20 on ultrasound. May be present in normal pregnancies, but
fetal chromosomal developmental abnormalities must be considered. Eti-
ologies include the following:
n Maternal DM
n Multiple gestation
n Isoimmunization
n Pulmonary abnormalities (eg, cystic lung malformations)
n Fetal anomalies (eg, duodenal atresia, tracheoesophageal fistula, anen-
cephaly)
n Twin-twin transfusion syndrome
n Hx/PE: Usually asymptomatic.
n Dx: Fundal height greater than expected. Evaluation includes ultrasound
for fetal anomalies, glucose testing for DM, and Rh screen.
n Tx: Etiology specific.
n Cx: Preterm labor, fetal malpresentation, cord prolapse
- 17—Oligohydramnios
n An AFI < 5 on ultrasound. Usually asymptomatic, but IUGR or fetal dis-
tress may be present.
n Etiologies include the following:
n Fetal urinary tract abnormalities (eg, renal agenesis, GU obstruction)
n Chronic uteroplacental insufficiency
n ROM
n Dx: The sum of the deepest amniotic fluid pocket in all 4 abdominal
quadrants on ultrasound.
n Tx: Rule out inaccurate gestational dates. Treat the underlying cause if
possible.
n Cx:
n Associated with a 40-fold ↑ in perinatal mortality.
n Other complications include musculoskeletal abnormalities (eg, club-
foot, facial distortion), pulmonary hypoplasia, umbilical cord compres-
sion, and IUGR.
- 18—Rh IsoImmunIzatIon
D iagnosis
Sensitized Rh- mothers with titers > 1:16 should be closely monitored with
serial ultrasound and amniocentesis for evidence of fetal hemolysis.
T reaTmenT
In severe cases, initiate preterm delivery when fetal lungs are mature. Prior
to delivery, intrauterine blood transfusions may be given to correct a low fetal
hematocrit.
- 19—GestatIonal tRophoblastIc DIsease (GtD)
t rEatmEnt
n Evacuate the uterus and follow with weekly β-hCG.
n Treat malignant disease with chemotherapy (methotrexate or dactinomy-
cin)
n Treat residual uterine disease with hysterectomy
n Chemotherapy and irradiation are highly effective for metastases.
- 20—multiple gestations
n Affect 3% of all live births.
n Since 1980, the incidence of monozygotic (identical) twins has remained
steady, while the incidence of dizygotic (fraternal) and higher-order births
has ↑.
n Hx/PE: Characterized by rapid uterine growth, excessive maternal weight
gain, and palpation of 3 or more large fetal parts on Leopold’s maneuvers.
n Dx: Ultrasound; hCG, human placental lactogen, and MSAFP are ele-
vated for GA.
n Tx:
n Multifetal reduction and selective fetal termination is an option for
higher-order multiple pregnancies.
n Antepartum fetal surveillance for IUGR.
n Management by a high-risk specialist is recommended.
n Cx:
n Maternal: Patients are 6 times more likely to be hospitalized with com-
plications of pregnancy.
n Fetal: Complications include twin-to-twin transfusion syndrome,
IUGR, preterm labor, and a higher incidence of congenital malforma-
tions
- 21—Abnormal Labor and Delivery
shoulDer DysTocia
Affects 0.6–1.4% of all deliveries in the United States. Risk factors include
obesity, diabetes, a history of a macrosomic infant, and a history of prior
shoulder dystocia.
D iagnosis
Diagnosed by a prolonged second stage of labor, recoil of the perineum (“tur-
tle sign”), and lack of spontaneous restitution.
t rEatmEnt
In the event of dystocia, be the mother’s HELPER:
n Help reposition.
n Episiotomy.
n Leg elevated (McRoberts’ maneuver; see Figure 2.11-11).
n Pressure (suprapubic).
n Enter the vagina and attempt rotation (Wood’s screw).
n Reach for the fetal arm
- 22—FAILURE TO PROGRESS
Associated with chorioamnionitis, occiput posterior position, nulliparity, and
elevated birth weight.
D IAGNOSIS
?? First-stage protraction or arrest: Labor that fails to produce adequate rates
of progressive cervical change.
?? Prolonged second-stage arrest: Arrest of fetal descent. See Table 2.11-16
for definitions based on parity and anesthesia.
T REATMENT
See Table 2.11-16.
C OMPLICATIONS
?? Chorioamnionitis leads to fetal infection, pneumonia, and bacteremia.
?? Permanent injury occurs in 10%.
?? The risk of postpartum hemorrhage is 11%; that of fourth-degree lacera-
tion is 3.8%
- 23—RUPTURE OF MEMBRANES (ROM)
n Preterm premature ROM (PPROM): ROM occurring at < 37 weeks’ ges-
tation.
n Prolonged ROM: ROM occurring > 18 hours prior to delivery. Risk fac-
tors include low socioeconomic status (SES), young maternal age, smok-
ing, and STDs.
- 24—PreTerm laBor
- 25—feTal malPresenTaTion
- 26—ePisioTomy
- 27—Puerperium
- 28—PosTParTum hemorrhage
- 29—PosTParTum infecTions
The 7 W’s of postpartum fever
(10 days postdelivery):
W omb (endomyometritis)
W ind (atelectasis, pneumonia)
W ater (UTI)
W alk (DVT, pulmonary embolism)
W ound (incision, episiotomy)
W eaning (breast engorgement, abscess,
mastitis)
W onder drugs (drug fever)
- 30—sheehan’s synDrome (PosTParTum PiTuiTary necrosis)
- 31—lactation and Breastfeeding
- 32—masTiTis
- 33—
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- Flashcards on GYNECOLOGY & OBSTETRICS CASES, created by Masar Algurapi on 14/01/2018.
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- Masar Algurapi
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