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329 Cards in this Set
- Front
- Back
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How do you manage vaginal vault prolapse
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pessary in non surgical candidates, sacrospinous ligament fixation, Abdominal sacrocolpopexy
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Perinatal death is
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stillbirth+ neonatal death
stillbirth= 20 wks gest to delivery neonatal=delivery to 28 wks postpartum |
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Criteria for APGAR score
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Muscle tone
Respirations Heart Rate Color Grimace (reflex irritability) |
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How many calories in bag of D5W
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50g of glucose x 4 cal/g=200calories
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Obstruction vs ileus
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Obstruction no gas in colon NG brown
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Where does ectopic rupture
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Antimesenteric side, why
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Spiegelberg criteria for diagnosis of ovarian pregnancy:
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* The gestational sac is located in the region of the ovary,
* the ectopic pregnancy is attached to the uterus by the ovarian ligament, * ovarian tissue in the wall of the gestational sac is proved histologically, * the tube on the involved side is intact. |
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Define WHI
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27,000 3 arms placebo, estrogen, combination HRT CEE 0.625 +MPA 2.5 mg/dl or CEE 0.625 mg/day
avg age 63, duration 5 yrs (7 in ET alone) Primary outcome CHD Primary adv outcome Invasive Br CA |
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Define WHI design
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under age 50 excluded
severe vasomotor systems excluded 50% current or former cigarette smokers Avg BMI 28.5 |
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Parvovirus fetal effects
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Aplastic anemia, craniofacial anomalies
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HIV in pregnancy
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viral load
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16 yo P0 4 cm endometrioma
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OCP asymptomatic, Sx symptomatic
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Tranfusion rx symptoms
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Symptoms Fever, Chills,Rash
Flank pain or back pain, Bloody urine Fainting or dizziness |
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What is hemolytic transfusion reaction
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Hemolytic transfusion reactions are the result of antibodies in the recipient's plasma directed against antigens on the donor's erythrocytes. This results in rapid intravascular hemolysis of the donor red blood cells. ABO incompatibility due to clerical error is the most frequent cause. This results in hemoglobinemia, hemoglobinuria, disseminated intravascular coagulation (DIC), renal failure, and complement-mediated cardiovascular collapse.
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Risk factor breech
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poly, multiparous, fetal anomaly, uterine anomaly, anacephaly, twins, previa, hydrocephalis, neuro anomalies
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Describe breeches
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Frank
Footling Complete |
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What is a Nonhemolytic febrile reaction of transfusion?
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Nonhemolytic febrile reactions are thought to stem from the formation of cytokines during the storage of the blood. These reactions seldom proceed to hypotension or respiratory distress.
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Anaphylactic reactions are associated with the following in tranfusions
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* Anaphylactic reactions are associated with the following:
* Tachycardia * Flushing * Urticaria * In more severe cases, wheezing, laryngeal edema, and hypotension |
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How do you deliver a breech?
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Up to umbilicus.
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Indications APT?
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CHTN
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Treatments medical for endometriosis
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GnRH agonists, and androgens. Oral norethindrone acetate and subcutaneous DMPA have been approved by the U.S. Food and Drug Administration (FDA) for treatment of endometriosis-associated pain. Danazol is an androgenic drug that has been used for the treatment of endometriosis-associated pain. Although highly effective, Danazol has a side effect profile, which includes acne, hirsutism, and myalgias, that is more severe than other drugs available.
Gonadotropin-releasing hormone agonists are highly effective in reducing the pain syndromes associated with endometriosis (79). However, they are not superior to other methods such as combined OCs as first-line therapy (71). Gonadotropin-releasing hormone agonists may have significant side effects, including hot flushes, vaginal dryness, and osteopenia. Osteopenia has been shown to be reversible with short-term use, but may not be with long-term use or use of multiple cycles |
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Uterine aa embololization procedure. what is post embolization sndrome
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Iv dye Femoral fluoroscopy spheres inj uterine aa. gelatin sponge, poly vinyl alcohol.
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Tamponade techniques PP hemorrhage
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Segmore Blakestein, Baraki balloon, packing uterus kerlex/thrombin
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Different Blood Products transfusion
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pRBC
FFP (anti III, V, VIII) Croppt (8,13, VWDs) |
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Drugs/MOA doses (max) PP Hemorrage
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Hemabate pgf2alpha inc ca 2 mg (0.25 IM q 15-90 max 8 doses)
Pitocin 60U/24 hrs Methergine ergot, vasoconstriction 0.2mg |
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Types ablation
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*Water-thermachoice, hydrothermal ablation (saline 90C) avg time 10min
*Cryoablation 6mm probe transfer medium thomson expand gas under high pressure free -120C, lupron 10min usu US iceball progression *Novasure radiofrequency disposable gold plate bipolar, max 180 watts impedence 50 ohms (coagulated tissue increased impedence 90 seconds) max length 6.5 max width 5.5 (width at least 4cm) *rollerball 2.5mm endom resection *MEA Microwave endometrial ablation- reusable 95C works microwave freq 9.5 GHz, pretreat 3.75mg lupron 3.5 min avg time. used large uterus * |
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What is pH of female vagina
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3.8 to 4.5 during reproductive years
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Vaginitis consists of
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- Bacterial vaginosis 50%
– Candida 30% – Trichomonas 20% |
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What are common vulvar diagnosis and symptoms
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What are common vulvar allegens
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ALLERGENS
Benzocaine Preservatives Neomycin Latex condoms Chlorhexadine Lanolin Perfume Nail Polish |
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What is your differential diagnosis vulvar ulcer?
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Herpes Simplex Virus (HSV)
Syphilitic chancre Chancroid Lymphogranuloma venereum (LGV) Granuloma inguinale Cancer Erosive disease (lichens planus, procidentia) |
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Which vulvar lesions are painful?
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HSV, Chancroid, + Lymphogranuloma venereum
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What are the causative organisms for each of the following?
Chancroid Lymphogranuloma venereum (LGV) Granuloma inguinale |
Chancroid—Haemophilus ducreyi
Lymphogranuloma venereum (LGV)—Chlamydia trochomatis Granuloma inguinale—Klebsiella granulomatis (Calymmatobacerium granulomatis) |
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How would you diagnose each of the following?
Herpes Simplex Virus (HSV) Syphilis Chancroid Lymphogranuloma venereum (LGV) Granuloma inguinale |
Herpes Simplex Virus (HSV): Viral culture, PCR, Serology
Syphilis : Darkfield microscopy, fluorescent antibody testing, serology Chancroid: Gram stain, culture, PCR Lymphogranuloma venereum (LGV): Culture, Serology Granuloma inguinale: Geimsa/Wright stain (Donovan bodies) |
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What is treatment for herpes?
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Acylovir 200mg 1 PO 5x/day x 10 days then 400mg 1 PO TID
Valocylovir 1 g BID x 10days then 500mg 1 PO BID |
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What is herpes? What LN like?
What incubation? What percent II vs I |
ds DNA virus
Incubation 3-7 days LN firm and tender 2/3, 1/3 |
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How counsel pt c herpes
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Vertical transmission
Prophylaxis Neonatal herpes- meningitis, encephalitis, cutaneous primary 50% disseminated 3% recurrent |
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2 weeks after SVD c/o flatus vaginal area dimple healing episiotomy
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r/o fistula
leak stool, urine return 6 weeks |
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What cause rectovaginal fistula
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• Congenital
• Traumatic – Obstetric – Blunt and penetrating injury – Foreign body • Pelvic irradiation • Infectious • Neoplastic |
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Define large bowel fistula
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• Definition
– Anovaginal = Near external sphincter – Rectovaginal = More than 3 cm from anus • Classification – Simple • Low or mid vagina, following trauma or infection – Complex • High vagina, from radiation or tumor |
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Where Ob fistula occur and risk factors?
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distal 1/3 rectum
communicate rectum at dentine line ob complication 3rd/4th previous surgery radiation unrecog lacertation forcep delivery trauma |
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Tx of fistula
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antibiotics
irrigation heal 6-12 weeks fiber heal completely persists uniflamted tampon methlene blue rectum transanal approach |
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High fistula surgery describe
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high fistula bowel resection with primary bowel reanastomosus
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Low fistula surgery describe
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fistulatomy with vaginal purse string method. expose fistula pursestring rectal lumen-small low fistulaes intact perineal body
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How diagnosis of fistula?
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• Diagnosis
– Air or stool from vagina – Recurrent vaginitis or cystitis – Perform vaginal and rectal examination – Confirmation • Barium or gastrografin enema • Fistulogram • Vaginogram – Colonoscopy can help |
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47yo P2 s/p Vaginal hysterectomy
new onset urinary incontinence DDx |
UTI
vesicovaginal urethral vaginal fistula |
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47yo P2 s/p Vaginal hysterectomy
new onset urinary incontinence How do you evaluate? |
Catherization urine, Cystogram, IVP, Neurogenic bladder check reflexed
Blue bladder see if tampon in vagina turns blue. Pyridium- tampon Orange uretrovaginal If radical hysterectomy- urethral vaginal fistulas |
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47yo P2 s/p Vaginal hysterectomy
new onset urinary incontinence Management? |
Infection treat
foley, PVR Fistula-leaks 24 hours atrophy restricted bladder incontinence fistula meds, PVR, urine c/s do voiding trial |
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47yo P2 s/p Vaginal hysterectomy
new onset urinary incontinence Fistula how repair? |
Repair
Technique - Excision of tract with closure - Latzko - Electrocautery or fibrin-based sealants - Principles - Multiple layers, no tension, healthy tissue - Identify ureteral orifices Post-op Management - Foley drainage - VCUG 7-10 days post-repair - Complications - Recurrent fistula - Stricture |
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Vesicovaginal Fistula
- risk factors -objective |
Risk factors
- Hysterectomy with bladder injury - Prolonged, obstructed labor History Subjective complaints - Constant urinary leakage, even at night - immediate vs. Onset 1-3 weeks post-event Objective findings - Vaginal vault with urine pooling on exam - May see area of inflammation/granulation tissue |
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How measure urethra?
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bladder urethral catheter mark urethra ends deflate foley bulb end foley 3.5-4 cm
Sling 2 cm urethra- |
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How do you do a voiding trial
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set volume
initally bladder emptied strile water until 300ml asked void spontaneously PVR- less 100 adeq bladder emptying |
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How diagnose and considerations of vesicovaginal fistula?
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Diagnosis
- Physical exam - Indigo dye testing - Cystourethrogram - Cystoscopy |
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Describe fucundability versus fecundity
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fundability-get prregnant
fecunidity-15% |
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28o 2 1st trimester miscarriage
DDx |
genetic, anatomic, metabolic, autoimmune, idiopathic, infectious, chromosomes
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28o 2 1st trimester miscarriage
thrombophelia |
Anticardiolipin test
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28o 2 1st trimester miscarriage
Management APS |
Lovenox 40mg sq, ASA
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Reversal for heparin is? dose?
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Dosage for heparin reversal is 1mg protamine sulfate i.v. for every 100 IU of active heparin
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Whats in FFP?
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factor 5, 8, antithrombin 3
volume 50cc |
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Reverse coumadin with? dose?
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give 5.0–10.0 mg vitamin K intravenously, as well as Prothrombinex-HT (25–50 IU/kg) and fresh frozen plasma (150–300 mL), assess patient continuously until INR < 5.0, and bleeding stops.
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Describe necrotizing fascitis and how present?
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SC infection from skin or viscus
– Endo/exotoxins cause ischemia, liquefaction necrosis, systemic illness – Erythema, edema, PAIN – Fever, shock, confusion, crepitus, bullae – CT may show fascial thickening or gas |
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Describe necrotizing fascitis describe types and treatment.
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25-35% mortality, increases c/ depth
* Type I: polymicrobial (55-75%) – Immunocompromised, post-op * Type II: Staph, Strep, Clostridia * Debridement(s) – Abx (Vanc, linezolid), hyperbaric O2, IVIg |
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Describe separation, deshisence, evisceration
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seperation- fascia intact
Dehiscence may stem from wound hematomas or from excessive intra-abdominal pressure secondary to abdominal coughing or vomiting that has disrupted the sutures. It is most commonly seen in patients with properties of poor wound healing, such as patients with diabetes, oncology patients, and patients taking steroid medications. Wound Dehiscence is the premature "bursting" open of a wound along surgical suture. It is a surgical complication that results from poor wound healing. Risk factors are age, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to the wound after surgery.Sometimes a pink (serosanguinous) fluid may leak out. evisceration- fascia separated bowel protrusion need surgical repair smead jones closure |
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Describe presentation Toxic shock syndrome
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Acute fever (>102F)
Diffuse erythematous eruption Multisystem involvement – N/V/D, myalgia, confusion, hypotension - Elevated: 2xnl BUN, Cr, ALT, AST, bili - Decreased plts <100K - Desquamation 1-2wks later - 25-48% mortality |
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What are causes of TTS? How Tx
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- S aureus, Clostridium sordelli, Strep A
– TSS toxin 1, enterotoxin B or C – Pt lacks toxin antibody - Drain infection site - Clindamycin – Suppresses toxin formation - Vancomycin (MRSA) - Supportive therapy, IVIg may help - Menstrual TSS rare since removal |
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Protamine is.... how does it reverse heparin?
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Protamine was originally isolated from the sperm of sharks and other species of fish but is now produced primarily through recombinant biotechnology. It is a highly cationic peptide. It binds to heparin to form a stable ion pair which does not have anticoagulant activity; on its own, protamine has a weak anticoagulant effect. The complex of heparin and protamine is then removed and broken down by the reticuloendothelial system.
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32 yo is c/o symptoms worseniing malstagia. DDX Tx
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Ddx
fibrocystic Mondors- superficial thrombosis of lateral thoracic vein Teize syndrome-costocondritis Tx- support analgesic decrease caffeine diuretic danazol 100mg BID mastalgia 3 types cyclic noncyclical nonmammary pain |
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Mastalgia worrisome for Cancer
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unilateral noncylic, intense progressive
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Danazol MOA
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Gonadotropin inhibitor—Danazol suppresses the pituitary-ovarian axis {01} possibly by inhibiting the output of pituitary gonadotropins. {12} Danazol also depresses the preovulatory surge in output of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) {01} and therefore reduces ovarian estrogen production. Danazol also may directly inhibit ovarian steroidogenesis, bind to androgen, progesterone, and glucocorticoid receptors, bind to sex-hormone–binding globulin and corticosteroid-binding globulin, and increase the metabolic clearance rate of progesterone.
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Locations ureter injury
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• Broad ligament
– Where ureter passes beneath the uterine a. • Cardinal ligament – As the ureter passes through its tunnel in the cardinal ligaments • Bladder wall – Intramural portion of the ureter • Pelvic brim – Where the ureter is adjacent to the ovarian a. |
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Danazol uses
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Endometriosis (treatment)—Danazol is indicated for the treatment of pain and/or {02} infertility due to endometriosis. {01} {12}
Breast disease, fibrocystic (treatment)—Danazol is indicated for the treatment of fibrocystic breast disease in patients whose symptoms are not relieved by analgesics, the use of well-fitted bras, or other simple methods. {01} {12} Angioedema, hereditary (prophylaxis)1—Danazol is indicated for the prophylactic treatment of hereditary angioedema (cutaneous, abdominal, and laryngeal) in males and females, {01} including prior to surgery. {08} {11} [Menorrhagia, primary (treatment)]—Danazol is indicated for short-term (up to 6 months) use in the treatment of severe primary menorrhagia at the time of expected menses in women with regular menstrual cycles. {12} Secondary menorrhagia manifest as abnormalities of blood coagulation (e.g., thrombocytopenia, von Willebrand's disease), endocrine disorders (e.g., hypothyroidism), or organic pathology (e.g., fibroids, genital neoplasia, polyps) should be ruled out prior to initiation of therapy. {12} [Gynecomastia (treatment)]1{15} or [Puberty, precocious (treatment)]1—Danazol is indicated for the treatment of gynecomastia and precocious puberty in females. |
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Complications spinal and epidural anesthesia
Types medications used |
Hypotension,Fever >100.4º (excess rate over women treated with narcotics),Postdural puncture headache, Transient fetal heart decelerations, Pruritus (with added opioid only)
Inadequate pain relief: epidural **Spinal A long-acting local anesthetic often is used, with or without an opioid agonist. The duration of anesthesia is approximately 30–250 minutes ***Modern epidural preparations that combine a low-dose local anesthetic, such as bupivacaine, levobupivacaine, or ropivacaine, with an opioid agonist are preferred because they decrease motor blockade and result in an increased rate of spontaneous vaginal delivery |
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Absolute Contraindications to Regional Anesthesia
How can the risk of maternal aspiration be minimized? |
Refractory maternal hypotension
Maternal coagulopathy Maternal use of once-daily dose of 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 The ASA Task Force on Obstetric Anesthesia recommends allowing a modest intake of clear liquids in patients experiencing normal labor (72). However, a fasting period of 6–8 hours for solids is preferable before elective cesarean delivery. For both elective and indicated cesarean delivery, agents to decrease gastric acidity should be used. Sodium citrate with citric acid |
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Leaking urine DDx
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qqq
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Induction of labor
medications, MOA and maximum doses |
aaa
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Muscles of pelvic floor are
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aaa
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Vulvar hematoma blood vessels involved treatment
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internal illiac broad ligament hematoma
pudendal vessels vaginal delivery Tx matress suture packing vagina embolization |
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Hysteroscopic media causing hyponatremia
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aaa
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Stages cervical cancer
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aaa
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Ectopic pregnancy
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AAA
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Which thyroid molecules X placenta
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not TSH
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CMV fetal affects
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microcephaly
oligohydram HSM jaundice Blue-berry muffin petechia |
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Varicella fetal risk of infection of primary, non-primary, recurrent infections?
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Neonatal infection at vaginal delivery
Primary HSV infection: 50% risk Non-primary first episode: 33% Recurrent infection (genital): 3% Recurrent infection (oral): ~0% Neonatal infection |
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Parvovirus fetal affects
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Rubella can cause congenital rubella syndrome in the newly born. The syndrome (CRS) follows intrauterine infection by Rubella virus and comprises cardiac, cerebral, ophthalmic and auditory defects. It may also cause prematurity, low birth weight, and neonatal thrombocytopenia, anaemia and hepatitis. The risk of major defects or organogenesis is highest for infection in the first trimester. CRS is the main reason a vaccine for rubella was developed. Many mothers who contract rubella within the first critical trimester either have a miscarriage or a still born baby. If the baby survives the infection, it can be born with severe heart disorders (PDA being the most common), blindness, deafness, or other life threatening organ disorders. The skin manifestations are called "blueberry muffin lesions
Skin lesions shed many months |
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How is HIV diagnosed
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Diagnosis:
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What are HIV targets for theraphy
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Fusion antigens
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infertility pt c inc fsh due to
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inhibin
avtivin stim fsh inhibin inhibits fsh foliistatin modulates fsh |
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62 yo vulvar itching DDX
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lichen sclerosis
lichen planus VIN vulvar carcinoma yeast vulvovaginitis atrophy |
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Risk factors VIN
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CIN
smoking HPV immunosupression multiple sexual partners |
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Most common cancer vulvar
% epidermoid |
scc vulvar
85% |
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Symptoms vulvar cancer
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puritis
palpable mass |
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Spread vulvar cancer
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superficial inguinal nodes
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Describe Vulvar lichen simplex
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Vulvar lichen simplex chronicus is a chronic eczematous disease characterized by scaling and lichenified plaque with intense and unrelenting itching
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Describe lichen sclerosis
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Lichen sclerosus, a chronic disorder of the skin, is most commonly seen on the vulva, with extragenital lesions reported in up to 13% of women with vulvar disease
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Cogwheel mumur what is it?
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Air and CO2 emboli are rare complications of hysteroscopy and may result in circulatory collapse. For such emboli to occur, there must be both vascular access and a pressure gradient between the site of access and the right side of the heart. In the conscious patient, chest pain and dyspnea may be noted. Other findings can include decreased oxygen saturation, the presence of a "mill wheel" heart murmur, hypotension, bradycardia, or tachycardia
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Cogwheel mumur how pt present?
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In the anesthetized patient, cardiopulmonary status shows signs of collapse with sudden hypotension, decrease in oxygenation and/or in endtidal CO2, or cardiac dysrhythmiasAir emboli SVC catheter Durant position left lateral air removed left atrium hypeerbaric O2
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Cogwheel mumur How Tx?
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Management of this emergency consists of placing the patient in a left lateral decubitus position with the head tilted downward 5 degrees. This maneuver favors the movement of air in the right ventricle and right ventricular outflow tract toward the apex of the right ventricle. The air may be aspirated by passing a catheter down the jugular vein into the right ventricle, or possibly by performing cardiocentesis.
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Osteoperosis meds that cause are?
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Steroids, Heparin, Phentyoin, Phenobarbital, Thyroxine high doses, Tamoxifen, Depot Provera, Lupron, TPN, Heparin (4-6 mo)
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Superficial epigastric branch of
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interior mamomary
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Inferior Epigastric aa branch of
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External illiac
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Explain hysteroscopes 3 types and assembly of parts and sizes
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Hysteroscopes are available in both flexible and rigid models, all of which contain a telescope consisting of light bundles. Flexible hysteroscopes range in diameter from 2.7 mm to 5 mm and have a bendable tip that can be deflected in two directions ranging from 120 degrees to 160 degrees. Most also contain an operating channel for tubal catheterization or endometrial biopsy. Rigid hysteroscopes may consist of two or three pieces and range from 1 mm to 5 mm in diameter. Their tips have varying viewing angles (0, 12, 15, 30, and 70 degrees). An outer sheath fits over the telescope to allow inflow of a distending medium into the intrauterine cavity. This system allows fluid to return on the outside of the outer sheath passively from the intrauterine cavity through the cervix.
Continuous flow hysteroscopes consist of two channels to allow fluid to flow into the intrauterine cavity while debris and cloudy intrauterine fluid exit through perforations in the outer sheath to the outflow port. Fluid exiting the outflow port can be collected through tubing and returned to a device for the accurate measurement of fluid volume. Operative hysteroscopes typically range from 8 mm to 10 mm in diameter and contain a working element. These hysteroscopes contain a retractable hand piece wherein electrosurgical tips (eg, rollerballs, loops, and vaporizing tips), lasers, or mechanical instruments (eg, scissors) can be attached. |
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Lupron given one week later has abdominal pain why?
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Lupron flare due endogenous estrogen release
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If using carbon dioxide in hysteroscopy what is flow needed to avoid gas emboli?
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To minimize the risk of gas embolization, the flow of CO2 should be limited to 100 mL/min with intrauterine pressures less than 100 mm Hg.
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What is the general types of fluid media in hysteroscopy
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Fluid media have historically been divided into electrolyte and nonelectrolyte media, based on compatibility with electrosurgical procedures. However, it is now possible to use electrolyte media with bipolar electrosurgical systems. It also is important to understand which media are hypoosmolar. Media also are categorized by viscosity.
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What is Low-Viscosity, Electrolyte-Poor Fluid in hysteroscopy and complications?
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Low-viscosity, electrolyte-poor fluids include glycine, 1.5%, sorbitol, 3%, and mannitol, 5%. These fluids have been widely used for operative hysteroscopy. They are compatible with radiofrequency energy, which cuts, desiccates, and fulgurates intrauterine tissue. Monopolar devices require electrolyte-poor fluids. If electrolyte-containing fluid is used, the electrical current will dissipate away from the electrode, rendering it ineffective. Glycine, 1.5%, and sorbitol, 3%, are hypoosmolar. The use of these fluids can cause hyponatremia and decreased serum osmolality, with the potential for cerebral edema and death. Some clinicians have recommended mannitol, 5%, which is isoosmolar and acts as its own diuretic. It may cause hyponatremia but not decreased serum osmolality
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What is Low-Viscosity Electrolyte Fluid in hysteroscopy and complications?
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Normal saline and lactated Ringer's solution are electrolyte fluids. The use of these fluids is advantageous because they are readily available and are isotonic. These solutions are the distending media of choice during diagnostic hysteroscopy and in operative cases where mechanical, laser, or bipolar energy is used. Although the risk of hyponatremia and decreased serum osmolality can be reduced by using these media, pulmonary edema can still occur, and careful attention should be paid to fluid input and output.
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What is High-Viscosity Fluid in hysteroscopy and complications?
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Dextran 70 is a colorless, viscous, polysaccharide liquid. The advantage of using this liquid is that it is immiscible with blood and, therefore, provides excellent visibility, especially in the presence of blood in the endometrial cavity. The major disadvantage of using dextran 70 is that it is sticky and, when dry, tends to harden and crystallize onto the equipment. It also can be a powerful plasma expander, and the volume usually is limited to 300 mL and must not exceed 500 mL. For every 100 mL absorbed, the plasma volume may expand by an additional 860 mL (2). Other concerns include anaphylaxis and disseminated intravascular coagulation. Beet sugar allergy is an absolute contraindication.
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What are contraindications for hysteroscopy?
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Known viable pregnancy, known genital tract infections, and known uterine carcinomas are contraindications to hysteroscopy. Theoretically, hysteroscopy may cause reflux of neoplastic cells into the peritoneal cavity, although it is unclear if this adversely affects the prognosis (4, 5). However, hysteroscopy is acceptable as part of the evaluation of abnormal uterine bleeding.
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What are complications of hysteroscopy?
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The most common perioperative complications associated with operative hysteroscopy are hemorrhage (2.4%), fluid overload (1.5%) (6), and cervical laceration (1–11%) (7). Other complications include uterine perforation, visceral injury, infection, CO2 and air embolism, and, rarely, death. Late complications may include intrauterine adhesions and infertility.
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Causes of bleeding from hysteroscopy and how to treat?
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Hemorrhage may occur during hysteroscopic resection of the endometrium, myomata, uterine septa, or synechia. For cases in which there is continued bleeding, electrosurgical coagulation can be used (8). Alternative strategies such as injection of vasopressin at the bleeding site, Foley catheter balloon tamponade (9), or irrigation of the uterine cavity with epsilon aminocaproic acid can be attempted. In extreme cases, uterine artery embolization or hysterectomy may be necessary.
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How to avoid fluid overload in hysteroscopy?
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Complications from fluid overload may best be avoided by limiting excess fluid absorption, recognizing and treating fluid overload promptly, and selecting a distending medium that minimizes risk.
The best way to limit excess fluid intravasation is to monitor the fluid deficit closely and frequently throughout the procedure. Newer methods of fluid monitoring based on measurement of fluid weight have made this more accurate; however, some of these systems can be expensive and may not be available in all settings. One difficulty in estimating fluid input and output is that commercially purchased 3-liter bags may be overfilled by up to 150–300 mL (10). Dilutional hyponatremia can be rapidly evaluated by serum sodium analysis. |
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With low-viscosity, electrolyte-poor fluids, a deficit of ???? mL implies excessive intravasation, and the fluid deficit should be monitored at an extremely close interval. In elderly patients, patients with comorbid conditions, and patients with cardiovascular compromise, consideration should be given to terminating the procedure immediately.
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750 ml
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Depending on patient size and other factors, if fluid deficit reaches ???mL of a nonelectrolyte solution or 2,500 mL of an electrolyte solution, further infusion should be stopped and the procedure should be promptly concluded. Electrolytes should be assessed, administration of diuretics considered, and further diagnostic and therapeutic intervention begun as indicated.
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1,000–1,500
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How should hyponatremia be treated in hysteroscopy?
|
Whereas most women recover, seizures, permanent brain damage, and death have been reported with serum sodium levels of 116 ± 2 mmol/L (11). Although the rate at which severe hyponatremia should be corrected is controversial, most authors agree that if acute hyponatremia has existed for less than 24 hours, there are few long-term complications from rapid correction. Therapy is most often provided in the form of hypertonic saline in conjunction with loop-acting diuretics. Serum sodium levels should be increased by 1–2 mEq/L/h but by no more than 12 mEq/L in the first 24 hours (12). When patients present with hyponatremia of greater than 48 hours postoperatively, rapid correction should not be undertaken because it can lead to neurologic compromise, seizures, and death. Consultation is strongly encouraged in these situations and often requires slower correction in an intensive care setting.
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Perforation of uterus in hysteroscopy should be
|
Prior to performing hysteroscopy, a pelvic examination should be performed to determine uterine position. If resistance is encountered during insertion of the hysteroscope, the cervix may need further dilation. Midline uterine perforation rarely leads to significant morbidity unless a laser or electrosurgical device is used. Lateral uterine or cervical perforations can result in significant bleeding. Laparoscopy may be useful to determine the extent of damage, including the existence of bowel or bladder injury.
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Cause SUI
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loss UV angle
loss intrabdominal urethra hypermobility of urethra |
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The physiologic changes over the course of pregnancy, including a plasma volume increase of approximately ____ and a red cell mass increase of approximately ____ occur in anticipation of the blood loss that will occur at delivery
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40%
25% |
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Hypotension, dizziness, pallor, and oliguria do not occur until blood loss is substantial—_____or more of total blood volume
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10%
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Postpartum hemorrhage generally is classified as primary or secondary define
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primary hemorrhage occurring within the first 24 hours of delivery and secondary hemorrhage occurring between 24 hours and 6–12 weeks postpartum
Primary Uterine atony Retained placenta–especially placenta accreta Defects in coagulation Uterine inversion Secondary Subinvolution of placental site Retained products of conception Infection Inherited coagulation defects |
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What are risk factors for PPH?
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Prolonged labor
Augmented labor Rapid labor History of postpartum hemorrhage Episiotomy, especially mediolateral Preeclampsia Overdistended uterus (macrosomia, twins, hydramnios) Operative delivery Asian or Hispanic ethnicity Chorioamnionitis |
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What should be considered in the initial evaluation of a patient with excessive bleeding in the immediate puerperium?
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Because the single most common cause of hemorrhage is uterine atony, the bladder should be emptied and a bimanual pelvic examination should be performed. The finding of the characteristic soft, poorly contracted ("boggy") uterus suggests atony as a causative factor. Compression or massage of the uterine corpus can diminish bleeding, expel blood and clots, and allow time for other measures to be implemented.
If bleeding persists, other etiologies besides atony must be considered. Even if atony is present, there may be other contributing factors. Lacerations should be ruled out by careful visual assessment of the lower genital tract. Proper patient positioning, adequate operative assistance, good lighting, appropriate instrumentation (eg, Simpson or Heaney retractors), and adequate anesthesia are necessary for the identification and proper repair of lacerations. Satisfactory repair may require transfer to a well-equipped operating room. The possibility that additional products of conception remain within the uterine cavity should be considered. curettage may identify a succenturiate lobe of the placenta or additional placental tissue. When a retained placenta is identified, a large, blunt instrument, such as a banjo curette or ring forceps, guided by ultrasonography, makes removal of the retained tissue easier and reduces the risk of perforation. Less commonly, postpartum hemorrhage may be caused by coagulopathy. Clotting abnormalities should be suspected on the basis of patient or family history or clinical circumstances. Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, abruptio placentae, prolonged intrauterine fetal demise, sepsis, and amniotic fluid embolism are associated with clotting abnormalities. Significant hemorrhage from any cause can lead to consumption of clotting factors. |
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How do you repair vaginal hematoma?
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Genital tract hematomas also can lead to significant blood loss. Progressive enlargement of the mass indicates a need for incision and drainage. Often a single bleeding source is not identified when a hematoma is incised. Draining the blood within the hematoma (sometimes placing a drain in situ), suturing the incision, and if appropriate, packing the vagina are measures usually successful in achieving hemostasis. Interventional radiology is another option for management of a hematoma. Genital tract hematomas may not be recognized until hours after the delivery, and they sometimes occur in the absence of vaginal or perineal lacerations. The main symptoms are pelvic or rectal pressure and pain.
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How do you assess if there is coagulopathy in PPH?
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Baseline studies include a complete blood count with platelets, a prothrombin time, an activated partial thromboplastin time, fibrinogen, and a type and cross order. The blood bank should be notified that transfusion may be necessary.
The clot observation test provides a simple measure of fibrinogen (10). A volume of 5 mL of the patient's blood is placed into a clean, red-topped tube and observed frequently. Normally, blood will clot within 8–10 minutes and will remain intact. If the fibrinogen concentration is low, generally less than 150 mg/dL, the blood in the tube will not clot, or if it does, it will undergo partial or complete dissolution in 30–60 minutes |
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What is the appropriate medical management approach for excessive postpartum bleeding?
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Oxytocin (Pitocin) IV: 10–40 units in 1 liter normal saline or lactated Ringer's solution IM: 10 units Continuous Avoid undiluted rapid IV infusion, which causes hypotension.
Methylergonovine (Methergine) IM: 0.2 mg Every 2–4 h Avoid if patient is hypertensive. 15-methyl PGF2 (Carboprost) (Hemabate) IM: 0.25 mg Every 15–90 min, 8 doses maximum Avoid in asthmatic patients; relative contraindication if hepatic, renal, and cardiac disease. Diarrhea, fever, tachycardia can occur. Dinoprostone (Prostin E2) Suppository: vaginal or rectal 20 mg Every 2 h Avoid if patient is hypotensive. Fever is common. Stored frozen, it must be thawed to room temperature. Misoprostol (Cytotec, PGE1) 800–1,000 mcg rectally |
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How do administer Factor VIIA?
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Human recombinant factor VIIa is a new treatment modality shown to be effective in controlling severe, life-threatening hemorrhage by acting on the extrinsic clotting pathway. Intravenous dosages vary by case and generally range from 50 to 100 mcg/kg every 2 hours until hemostasis is achieved. Cessation of bleeding ranges from 10 minutes to 40 minutes after administration (11–14). Concern has been raised because of apparent risk of subsequent thromboembolic events following factor VIIa use
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What is difference TTP HUS ITP Fatty Liver Pregnancy PreEclampsia?
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xxx
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When is packing or tamponade of the uterine cavity advisable?
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When uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after vaginal delivery, tamponade of the uterus can be effective in decreasing hemorrhage secondary to uterine atony Packing with gauze requires careful layering of the material back and forth from one cornu to the other using a sponge stick, packing back and forth, and ending with extension of the gauze through the cervical os. The same effect often can be derived more easily using a Foley catheter, Sengstaken-Blakemore tube, or, more recently, the SOS Bakri tamponade balloon 300-500cc saline
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When are surgical techniques used to control uterine bleeding?
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When uterotonic agents with or without tamponade measures fail to control bleeding in a patient who has given birth vaginally, exploratory laparotomy is indicated. A midline vertical abdominal incision usually is preferred to optimize exposure. Several techniques are available to control bleeding Uterine curettage
Uterine artery ligation Bilateral; also can ligate uteroovarian vessels B-Lynch suture Hypogastric artery ligation Less successful than earlier thought; difficult technique; generally reserved for practitioners experienced in the procedure Repair of rupture Hysterectomy |
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Why is hypogastric aa ligation performed?
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diminish the pulse pressure of blood flowing to the uterus via the internal iliac (hypogastric) vessels
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Beside hypogastric aa ligation what other atrerial occlusion can be done and is just as effective?
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Bilateral uterine artery ligation (O'Leary sutures) accomplishes the same goal, and this procedure is quicker and easier to perform (18, 19). To further diminish blood flow to the uterus, similar sutures can be placed across the vessels within the uteroovarian ligaments.
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When is B-lynch used?
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The B-Lynch technique is a newer procedure for stopping excessive bleeding caused by uterine atony (20). The suture provides even pressure to compress the uterine corpus and decrease bleeding. One study reported more than 1,000 B-Lynch procedures with only seven failures
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Beside B-lynch what is another method of compression?
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Hemostatic multiple square suturing is another new surgical technique for postpartum hemorrhage caused by uterine atony, placenta previa, or placenta accreta. The procedure eliminates space in the uterine cavity by suturing both anterior and posterior uterine walls.
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What are the clinical (risks)considerations for suspected placenta accreta?
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Risk factors for placenta accreta include placenta previa with or without previous uterine surgery, prior myomectomy, prior cesarean delivery, Asherman's syndrome, submucous leiomyomata, and maternal age older than 35 years
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What are risks of accreta c increasing c/s rate.
How do these #'s change if these pts also have previas and hx c/s #1-6??? |
Prior cesarean delivery and the presence of placenta previa in a current pregnancy are particularly important risk factors for placenta accreta. In a multicenter study of more than 30,000 patients who had cesarean delivery without labor, the risk of placenta accreta was approximately 0.2%, 0.3%, 0.6%, 2.1%, 2.3%, and 7.7% for women experiencing their first through sixth cesarean deliveries, respectively. In patients with placenta previa in the current pregnancy, the risk of accreta was 3%, 11%, 40%, 61%, and 67% for those undergoing their first through their fifth or greater cesarean deliveries, respectively
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If the diagnosis or a strong suspicion of accreta is formed before delivery, a number of measures should be taken what are they?
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The patient should be counseled about the likelihood of hysterectomy and blood transfusion.
Blood products and clotting factors should be available. Cell saver technology should be considered if available. The appropriate location and timing for delivery should be considered to allow access to adequate surgical personnel and equipment. A preoperative anesthesia assessment should be obtained. |
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In PPH under what circumstances is arterial embolization indicated?
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stable vital signs and persistent bleeding, especially if the rate of loss is not excessive, may be a candidate for arterial embolization
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When is blood transfusion recommended?
Is there a role for autologous transfusions or directed donor programs? |
Transfusion of blood products is necessary when the extent of blood loss is significant and ongoing, particularly if vital signs are unstable, determination of hematocrit or hemoglobin concentrations may not accurately reflect the current hematologic status, and symptoms and signs of hemorrhage may not occur until blood loss exceeds 15%
Autologous transfusion generally is reserved for situations with a high chance of transfusion in a patient with rare antibodies, where the likelihood of identifying compatible volunteer-provided blood is very low. |
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What is the management approach for hemorrhage due to a ruptured uterus?
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Rupture can occur at the site of a previous cesarean delivery or other surgical procedure involving the uterine wall from intrauterine manipulation or trauma or from congenital malformation (small uterine horn), or it can occur spontaneously. Abnormal labor, operative delivery, and placenta accreta can lead to rupture. Surgical repair is required, with the specific approach tailored to reconstruct the uterus, if possible. Care depends on the extent and site of rupture, the patient's current clinical condition, and her desire for future childbearing. Rupture of a previous cesarean delivery scar often can be managed by revision of the edges of the prior incision followed by primary closure. In addition to the myometrial disruption, consideration must be given to neighboring structures, such as the broad ligament, parametrial vessels, ureters, and bladder. Regardless of the patient's wishes for the avoidance of hysterectomy, this procedure may be necessary in a life-threatening situation.
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Tell volume contents effect for pRBC? (chart PB 76)
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Packed red cells 240 Red blood cells, white blood cells, plasma Increase hematocrit 3 percentage points, hemoglobin by 1 g/dL
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Tell volume contents effect for Platlets? (chart PB 76)
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Platelets 50 Platelets, red blood cells, white blood cells, plasma Increase platelet count 5,000– 10,000/mm3 per unit
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Tell volume contents effect for FFP? (chart PB 76)
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Fresh frozen plasma 250 Fibrinogen, antithrombin III, factors V and VIII Increase fibrinogen by 10 mg/dL
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Tell volume contents effect for Cryoprecipitate? (chart PB 76)
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Cryoprecipitate 40 Fibrinogen, factors VIII and XIII, von Willebrand factor Increase fibrinogen by 10 mg/dL
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What is the management approach for an inverted uterus? describe findings methods replacement
|
Uterine inversion, in which the uterine corpus descends to, and sometimes through, the uterine cervix, is associated with marked hemorrhage. On bimanual examination, the finding of a firm mass below or near the cervix, coupled with the absence of identification of the uterine corpus on abdominal examination, suggests inversion. If the inversion occurs before placental separation, detachment or removal of the placenta should not be undertaken; this will lead to additional hemorrhage. Replacement of the uterine corpus involves placing the palm of the hand against the fundus (now inverted and lowermost at or through the cervix), as if holding a tennis ball, with the fingertips exerting upward pressure circumferentially (34). To restore normal anatomy, re-laxation of the uterus may be necessary. Terbutaline, magnesium sulfate, halogenated general anesthetics, and nitroglycerin have been used for uterine relaxation.
Manual replacement with or without uterine relaxants usually is successful. In the unusual circumstance in which it is not, laparotomy is required. Two procedures have been reported to return the uterine corpus to the abdominal cavity. The Huntington procedure involves progressive upward traction on the inverted corpus using Babcock or Allis forceps (35). The Haultain procedure involves incising the cervical ring posteriorly, allowing for digital repositioning of the inverted corpus, with subsequent repair of the incision (36). |
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What is the management approach for secondary postpartum hemorrhage?
What % pregnancy occurs in, what has high prevalence what should be done first what must you consent patients for? |
Secondary hemorrhage occurs in approximately 1% of pregnancies; often the specific etiology is unknown. Postpartum hemorrhage may be the first indication for von Willebrand's disease for many patients and should be considered. The prevalence of von Willebrand's disease is reported to be 10–20% among adult women with menorrhagia (37). Hence, testing for bleeding disorders should be considered among pregnant patients with a history of menorrhagia because the risk of delayed or secondary postpartum hemorrhage is high among women with bleeding disorders (38, 39).
Uterine atony (perhaps secondary to retained products of conception) with or without infection contributes to secondary hemorrhage. The extent of bleeding usually is less than that seen with primary postpartum hemorrhage. Ultrasound evaluation can help identify intrauterine tissue or subinvolution of the placental site. Treatment may include uterotonic agents, antibiotics, and curettage. Often the volume of tissue removed by curettage is minimal, yet bleeding subsides promptly. Care must be taken in performing the procedure to avoid perforation of the uterus. Concurrent ultrasound assessment at the time of curettage can be helpful in prevent-ing this complication. Patients should be counseled about the possibility of hysterectomy before initiating any operative procedures. |
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What is the best approach to managing excessive blood loss in the postpartum period once the patient's condition is stable?
What can you give PO and what change of subsequent PPH? |
Regardless of the cause of postpartum hemorrhage, subsequent replacement of the red cell mass is important. Along with a prenatal vitamin and mineral capsule daily (which contains about 60 mg of elemental iron and 1 mg folate), two additional iron tablets (ferrous sulfate, 300 mg, each yielding about 60 mg of elemental iron) will maximize red cell production and restoration. Erythro-poietin can hasten red cell production in postpartum anemic patients to some extent, but it is not approved by the U.S. Food and Drug Administration for postoperative anemia, and it can be costly (40). Postpartum hemorrhage in a subsequent pregnancy occurs in approximately 10% of patients
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What is findings of teralogy fallot?
|
Tetrology of Fallot accounts for approximately 10% of all fetal cardiac defects. This lesion is not easily or reliably recognized by ultrasound. The salient features are the relatively large right ventricle, the large ventricular septal defect, and the enlarged aortic orifice. Recognition of an overriding aorta in the fetus is not always possible. The prognosis of Tetralogy of Fallot is generally good but will vary according to associated anomalies. Tetralogy of Fallot is associated with trisomy 13, 18, and 21. It may also be seen with microdeletion of chromosome 22q, DiGeorge syndrome, CHARGE syndrome, and the complex of VATER anomalies. Ebstein's anomaly is typically associated with lithium use in early pregnancy.
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What is placenta increta
|
Choronic villi invade myometrium.
In placenta accreta, the anchoring villi attach to the myometrium; in placenta increta, the villi invade into the myometrium; and in placenta percreta, the villi penetrate to or through the uterine serosa and may invade surrounding organs. |
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What is placenta percreta
|
Choronic villi penetrate to or through uterine serosa and may invade surrounding organs
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What does accreta look like on US?
|
The normal placental implantation is characterized by continuity of the bladder wall, a hypoechoic interface between the bladder wall and the placenta (ie, myometrium and the normal retroplacental myometrial vasculature), and homogeneity of the placental mass. When placenta accreta is present, the hypoechoic boundary is lost and the placenta appears contiguous with the bladder wall
Diffuse and focal intraparenchymal placental lacunar flow Hypervascularity of the bladder and uterine serosa Prominent subplacental venous complex Loss of subplacental Doppler vascular signals |
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What are complications of accreta
|
Massive hemorrhage is the most common complication of placenta accreta. Potential sequelae of massive hemorrhage include disseminated intravascular coagulopathy, adult respiratory distress syndrome, renal failure, unplanned surgery, and death
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How surgically do you manage accreta?
|
We frequently utilize balloon catheters for our patients with suspected accreta and believe that these catheters are helpful in controlling hemorrhage. Balloon occlusion of the aorta or internal iliac vessels is intended to prevent hemorrhage at the time of mobilization of the bladder flap and dissection of the lower uterine segment The procedure involves preoperative placement of balloon catheters retrograde through the femoral arteries under fluoroscopic guidance. The catheters are then guided into the internal iliac arteries. Balloons may be inflated intermittently for up to 20 minutes during the hysterectomy, thus markedly decreasing blood loss. A vertical skin incision provides good exposure. The pelvis is inspected for evidence of percreta and the location of any collateral blood supply. A bladder flap is created if the area appears clear of adhesions and placenta. A vertical uterine incision is made above the placenta to avoid disrupting it and the infant is delivered.
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What are stage of NYHA?
|
Stage 1
Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. Ordinary physical activity, such as walking and climbing stairs, does not cause angina. Angina with strenuous or rapid prolonged exertion at work or recreation. Patients can perform to completion any activity requiring ≥7 metabolic equivalents, eg, can carry 24 lb up eight steps; do outdoor work (shovel snow, spade soil); do recreational activities (skiing, basketball, squash, handball, jog/walk 5 mph). Stage 2 II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, in wind, or when under emotional stress, or only during the few hours after awakening. Walking more than two blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions. Patients can perform to completion any activity requiring ≤ 5 metabolic equivalents, eg, have sexual intercourse without stopping, garden, rake, weed, roller skate, dance fox trot, walk at 4 mph on level ground, but cannot and do not perform to completion activities requiring ≥ 7 metabolic equivalents. Stage 3 III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain. Marked limitation of ordinary physical activity. Walking one to two blocks on the level and climbing more than one flight in normal conditions. Patients can perform to completion any activity requiring ≤ 2 metabolic equivalents, eg, shower without stopping, strip and make bed, clean windows, walk 2.5 mph, bowl, play golf, dress without stopping, but cannot and do not perform to completion any activities requiring > 5 metabolic equivalents. Stage 4 IV Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased. Inability to carry on any physical activity without discomfort - anginal syndrome may be present at rest. Patients cannot or do not perform to completion activities requiring > 2 metabolic equivalents. Cannot carry out activities listed above (Specific activity scale III). |
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Anterior branch internal illiac
|
OUUMII
inferior gluteal artery, middle rectal artery, uterine artery, obturator artery, inferior vesical artery, superior vesical artery, obliterated umbilical artery, internal pudendal artery |
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Posterior division internal illiac
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iliolumbar artery, lateral sacral artery, superior gluteal artery
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Superior vesicle aa comes off
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umbilical artery
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Branches external illiac aa
|
inferior epigastric (round ligament) · deep circumflex iliac · femoral
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Incidence DS 30,35,40,45
Incidence any chrom abnormality |
1/1000
1/365 1/100 1/36 any chrom abn cut numbers in 1/2 |
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What is average weight fetus 34 weeks
|
34 weeks 2000g
each week 250g 36 weeks 2500g 38weeks 3000g |
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Tell about granulosa cell tumors
|
granulosa =stromal tumor
great TITS =produce estrogen call girl=call extner bodies inhibitions =inhibin uptight in groove= nuclear grooves come beack haunt you later=tumors late recurrence |
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Whats in Bishop score
|
bishop
DES-CP Dilitation-3 Effacement-3 Station-3 Consistency-2 Position-2 |
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Difference Vilamentous, Vasaprevia, Batteldorf, Succinturate lobe
|
A velamentous cord insertion refers to a cord that inserts into the membranes rather than the placental disk. The velamentous vessels are surrounded only by fetal membranes, with no Wharton's jelly, thus they are prone to compression or disruption
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What are 5 A's smoking cessation
|
ASK the patient about smoking status at the first prenatal visit and follow-up with her at subsequent visits. The patient should choose the statement that best describes her smoking status:
A. I have NEVER smoked or have smoked LESS THAN 100 cigarettes in my lifetime. B. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now. C. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now. D. I smoke some now, but I have cut down on the number of cigarettes I smoke SINCE I found out I was pregnant. E. I smoke regularly now, about the same as BEFORE I found out I was pregnant. If the patient stopped smoking before or after she found out she was pregnant (B or C), reinforce her decision to quit, congratulate her on success in quitting, and encourage her to stay smoke free throughout pregnancy and postpartum. If the patient is still smoking (D or E), document smoking status in her medical record, and proceed to Advise, Assess, Assist, and Arrange. ADVISE the patient who smokes to stop by providing advice to quit with information about the risks of continued smoking to the woman, fetus, and newborn. ASSESS the patient’s willingness to attempt to quit smoking at the time. Quitting advice, assessment, and motivational assistance should be offered at subsequent prenatal care visits. ASSIST the patient who is interested in quitting by providing pregnancy-specific, self-help smoking cessation materials. Support the importance of having smoke-free space at home and seeking out a “quitting buddy,” such as a former smoker or nonsmoker. Encourage the patient to talk about the process of quitting. Offer a direct referral to the smoker’s quit line (1-800-QUIT NOW) to provide ongoing counseling and support. ARRANGE follow-up visits to track the progress of the patient’s attempt to quit smoking. For current and former smokers, smoking status should be monitored and recorded throughout pregnancy, providing opportunities to congratulate and support success, reinforce steps taken towards quitting, and advise those still considering a cessation attempt |
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What are fetal effects of smoking?
|
These include intrauterine growth restriction, placenta previa, abruptio placentae, decreased maternal thyroid function, preterm premature rupture of membranes, low birth weight, perinatal mortality, and ectopic pregnancy
Children born to mothers who smoke during pregnancy are at an increased risk of asthma, infantile colic, and childhood obesity |
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What are examples of interventions to quit smoking
|
Physician advice regarding smoking related risks (2–3 minutes)
Video tape with information on risks, barriers, and tips for quitting; provider counseling in one 10-minute session; self-help manual; and follow-up letters Pregnancy-specific self-help guide and one 10-minute counseling session with a health educator. Provide counseling in one 90-minute session plus twice monthly telephone follow-up calls during pregnancy and monthly telephone calls after delivery |
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What Rx to use in pregnancy to help quit smoking
|
nicotine replacement therapy should be undertaken with close supervision and after careful consideration and discussion with the patient of the known risks of continued smoking and the possible risks of nicotine replacement therapy. If nicotine replacement is used, it should be with the clear resolve of the patient to quit smoking.
Alternative smoking cessation agents used in the nonpregnant population include varenicline and bupropion. Varenicline is a drug that acts on brain nicotine receptors, but there is no knowledge as to the safety of varenicline use in pregnancy (27). Bupropion is an antidepressant with only limited data, but there is no known risk of fetal anomalies or adverse pregnancy effects (28). However, both of these medications have recently added product warnings mandated by the U.S. Food and Drug Administration about the risk of psychiatric symptoms and suicide associated with their use (29, 30). Both bupropion and varenicline are transmitted to breast milk. There is insufficient evidence to evaluate the safety and efficacy of these treatments in pregnancy and lactation |
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mass closure, Smead Jones Modified smead jones,
|
O-PDS delayed absorbable
Running stich Smead jones far near far closure Modified far far near near interrupted or running future |
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Restless leg syndrome what is it.
|
Tx gapentin, clonapine, feeling restless nighy leg movements
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What is smead jones versus modified smead jones?
|
Smead-Jones technique
“Running” closure technique used to approximate abdominal fascia, rectus muscles, and anterior peritoneum; closure favored by gynecologists. Alternating different-size tissue bites are taken in “over and over” fashion; double-looped 0 Maxon suture can be used. Modified smead jones is interrupted closure of the abdominal wall using nonabsorbable suture material, with sutures taken in a ′far near-near far |
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What is peripartum myopathy
|
PPCM is defined by the development a reduced LVEF in the last month of pregnancy or within five months of delivery, in the absence of an identifiable cause for the cardiac failure or recognizable heart
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4 criteria for peripartum cardiopathy
|
Four criteria are needed to meet the definition of peripartum cardiomyopathy
Development of cardiac failure in the last month of pregnancy or within five months of delivery. Absence of an identifiable cause for the cardiac failure. (See "Causes of dilated cardiomyopathy".) Absence of recognizable heart disease prior to the last month of pregnancy. LV systolic dysfunction (eg, left ventricular ejection fraction [LVEF] below 45 percent or a reduced shortening fraction). |
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What cytokines associated with peripartum cardiomyopathy?
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TNFalpha, IL6 severe disease FAS/Apo-1
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Acute fatty liver preganancy
|
glucose lowered, Ammonia high
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Bradycardia caused by
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hypoxic baroreceptor and chemoreceptor response mediates vagus nerve
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What are risk factors for peripartum cardiomyopathy?
|
Age greater than 30 years Multiparity
African descent Pregnancy with multiple fetuses A history of preeclampsia, eclampsia, or postpartum hypertension Maternal cocaine abuse Long term (>4 weeks) oral tocolytic therapy with beta adrenergic agonists such as terbutaline There are conflicting data as to whether selenium deficiency or is not a risk factor for PPCM. |
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What is autonomic dyreflexia what concerns for obstetric pt what symptoms?
|
Patients at risk
◦ 85% of patients with lesions above T5/T6 |
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What is the general management guidelines for women with cardiac disease during labor?
|
o Epidural anesthesia (when hypotension is avoided) is preferred
o Vaginal delivery is preferred and cesarean delivery is not indicated for most cardiovascular conditions o Avoid sudden vascular fluid shifts and sudden changes in heart rate and blood pressure. |
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What are fetal complications of obesity?
|
Increased incidence
NTD IUFD (OR 2.07) U/S limitations Fetal macrosomia Childhood obesity |
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What are signs/symptoms of unrecognized ureteral injury?
|
Flank pain
• Abdominal pain • Fever • Peritoneal signs • Hematuria • Oliguria • Anuria • New ascites • Pelvic mass |
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How does on repair ureter injury at different levels?
|
• Ureteroneocystotomy
– Injuries close to bladder – Near brim, may require psoas hitch – If tension, may require Boari flap • Ureteroureterostomy – Above pelvic brim • Transureteroureterostomy – High above pelvic brim • Nephrostomy • Nephrectomy |
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How do you manage a ureteral injury?
|
• Dictated by:
– Timing of diagnosis – Medical condition – Infection or hematoma – Type of repair planned • If recognized early (2-3 days): – Remove ligation – Reimplantation • If recognized late (2-3 weeks): – Protect renal unit (nephrostomy or stent) – Delayed repair after inflammation resolves |
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What is vascular supply of the ureter?
|
• General principles
– Upper ureter (abdominal): From medial • Ovarian artery • Renal artery • Aorta • Common iliac artery – Lower ureter (pelvis): From lateral • Internal iliac artery • Throughout its length, blood supply courses through ureteral adventitia |
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What are types urinary fistulas?
|
• Locations
– Bladder (vesicovaginal) – Ureter (ureterovaginal) – Unilateral or bilateral – Both |
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How does urinary fistulas present?
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• Presentation
– Fistula usually occur 10-14 days of injury – Symptoms • Watery (uriniferous) vaginal discharge • Pain • Fever – Discharge immediately after surgery = direct urinary tract injury – Discharge later suggest indirect injury (from devascularization) |
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How do ou diagnoses a urinary fistula?
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• Diagnosis
– Most are not visible – “3 tampon test of Moir” • Tests for a vesico- or ureterovaginal fistula • 3 tampons in vagina – blue saline in bladder – If one is present, must rule out other(s) – Cystoscopy – Cystography – Fistulogram (vaginogram) – IVP – Creatinine on any fluid |
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How do you manage a urinary fistula?
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• Management
– Continuous bladder drainage • 10% of very small fistulas will heal spontaneously with bladder drainage for up to 4 weeks • Problems with staying dry – Immediate repair (within first month) • Good tissue mobility • Less intense inflammation • Adequate vascularity – Delayed repair (after 3 months) • Minimization of adhesions • Better tract epithelialization • More wet days compared with early repair |
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How do repair fistua of bladder?
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• Management
– Continuous bladder drainage • 10% of very small fistulas will heal spontaneously with bladder drainage for up to 4 weeks • Problems with staying dry – Immediate repair (within first month) • Good tissue mobility • Less intense inflammation • Adequate vascularity – Delayed repair (after 3 months) • Minimization of adhesions • Better tract epithelialization • More wet days compared with early repair Repair in 3 layers if possible |
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What DDx of menstral disorders in adolescents?
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ACOG guidelines for VWF testing?
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LGV define?
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C. Trachomatis, No pain, no induration, Dx PCR
3stages papulae, inguinopathy, craters |
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What is lab evaluation of VWD?
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How to treat endometriosis in adolescent?
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Trial of NSAIDS or cyclic OCP’s for 3 months
L/S with biopsy and conservative, organ-sparing surgery for all failures <18 years old (MUST LOOK FOR CLEAR OR RED LESIONS) GnRH agonist therapy for postop continuous OCP failures only if > 16 YEARS OLD |
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How does lichen sclerosis present?
Tx? |
Dermatosis of unknown etiology (autoimmune?)
Intense, often intractable pruritus (scratches in public, sleep, etc.) |
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How do you treat DKA in pregnancy?
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1. Laboratory assessment:
Obtain arterial blood gases to document degree of acidosis present; measure glucose, ketones, electrolytes, at 1- to 2-hour intervals. 2. Insulin Low-dose, intravenous (IV) Loading dose: 0.2-0.4 units/kg Maintenance: 2.0-10.0 units/h 3. Fluids: Isotonic NaCl Total replacement in first 12 h = 4-6L 1 L in first hour 500-1,000 ml/h for 2-4 h 250 ml/h until 80% replaced 4. Glucose: Begin 5% D/NS* when plasma level reaches 250 mg/dL (14 mmol/L) 5. Potassium: If initially normal or reduced, an infusion rate up to 15 to 20 mEq/h may be required; if elevated, wait until levels decline into the normal range, then add to IV solution in a concentration of 20-30 mEq/L 6. Bicarbonate: Add one ampule (44 mEq) to 1 L of 0.45 NS if pH is <7.10 |
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What are types ketones?
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acetoacetae, B-hydroxy-buterate, acetone
Ketone breakdown fat |
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What is management of glucose in labor of DM patient?
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Intrapartum glycemic control
Objectives: Avoid intrapartum maternal hyperglycemia Avoid fetal hyperglycemia Avoid neonatal hypoglycemia Avoid postpartum maternal hypoglycemia 1. Manage with intravenous insulin infusion and hourly capillary glucose measurements a. 10 units of regular insulin in 1,000 ml of D5 at 100-125 ml/hr. b. Maintain maternal glucose at ~ 100 mg/dL |
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What are dietary recommendations in pregnancy?
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Plan 3 meals, 3 snacks
30 kcal/kg normal weight 24 kcal/kg>120% desirable 36-40 kcal/kg<90% desirable B.W. Diet 2000-2400 kcalories daily Carbohydrate: 40-50%, complex high fiber Protein: 20% Composition Fat: 30-40% (<10% saturated) 28-40 lbs. <90% B.W. 25-35 lbs. Desirable B.W. Weight Gain 15-25 lbs. >135% B.W. |
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How much will 1 unit of short acting insulin lower my blood
glucose? |
Approximately 30 mg/dL
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How much will 10 grams of carbohydrate elevate my blood
glucose? |
Approximately 30 mg/dL
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How do you administer insulin in pregnancy?
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Regular or Insulin Lispro and NPH/Lente – 2 injections
2/3 of total dose in morning with NPH: regular or insulin lispro 2:1 1/3 of total dose at dinner with NPH: regular or insulin lispro 1:1 |
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For each Insulin state onset, peak, duration of action
Lispro (Humalog) |
Lispro (Humalog),
Aspart (Novolog) onset1-15 min peak 1-2 hrs duration 4-5 hrs |
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For each Insulin state onset, peak, duration of action
Regular |
Regular
Onset 30-60 min Peak 2-4 hrs Duration 6-8 hrs |
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For each Insulin state onset, peak, duration of action
NPH |
NPH
Onset1-3 hrs Peak 5-7 hrs Duration 13-18 hrs |
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For each Insulin state onset, peak, duration of action
Lente |
Lente
Onset 1-3 hrs Peak 4-8 hrs Duration 13-20 hrs |
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How is Cystic Fibrosis defined?
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Both of the following criteria must be met to diagnose CF
Clinical symptoms consistent with CF in at least one organ system Evidence of CFTR dysfunction (any of the following): - Elevated sweat chloride >60 mmol/L (on two occasions) - Presence of two disease-causing mutations in CFTR - Abnormal nasal potential difference The accuracy of sweat chloride and nasal potential difference measurements are operator-dependent, so it is critical that testing be performed in experienced centers, following standard guidelines. Delta F508 mutation |
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What are clinical features of cystic fibrosis
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conductance regulator (CFTR) protein, a complex chloride channel and regulatory protein found in all exocrine tissues [6-9]. Deranged transport of chloride and/or other CFTR-affected ions, such as sodium and bicarbonate, leads to thick, viscous secretions in the lungs, pancreas, liver, intestine, and reproductive tract, and to increased salt content in sweat gland secretions [1,7,10]. The typical CF patient presents with multisystem disease involving several or all of these organs (table 2). (See "Cystic fibrosis:
Typical respiratory manifestations of CF include a persistent, productive cough, hyperinflation of the lung fields on chest radiograph, and pulmonary function tests that are consistent with obstructive airway disease. As the disease progresses, chronic bronchitis with or without bronchiectasis develops and is accompanied by acute exacerbations characterized by increased cough, tachypnea, dyspnea, increased sputum production, malaise, anorexia and weight loss. Digital clubbing is often seen in patients with moderate to advanced disease. Insufficient secretion of digestive enzymes such as lipase leads to malabsorption of fat (with steatorrhea) and protein. Failure to thrive is a presenting sign in many infants and children; less commonly, infants may present with a syndrome of variable hypoproteinemia, edema, electrolyte loss, and anemia due to malabsorptive nutrient deficiencies. |
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How does CF present in neonate
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Meconium ileus is the presenting problem in 10 to 20 percent of newborns with CF, and is virtually pathognomonic of the disease
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How can CF affect males fertility?
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Most of these men have incompletely developed Wolffian structures, most commonly absent vas deferens. These anomalies probably reflect a critical role for CFTR in the organogenesis of these structures. Nearly half of all men with congenital bilateral absence of the vas deferens and normal lung function have two CFTR mutations
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In CF patient becomes pregnant what FEv1 needed?
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50-60% of predicted value
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What are algorithms for testing for CF if suspected?
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1. wait infant .>2 wks sweat chloride greater 60 mmol/L DNA testing 2 CF mutations diagnosed
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What is cytogenic of CF?
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Delta F508 most common mutation is Askenazi Jewish W1282X. Long arm chromosome 7 Cystic fibrosis conductance transmembrane regulator protein (CFTR)
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Who should be offered CF testing?
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Screening for CF should be offered to the following patients
Individuals with a family history of CF in a first or second degree relative Reproductive partners of individuals who have CF Couples in whom one or both partners are Caucasian and of European or Ashkenazi Jewish descent and who are planning a pregnancy or seeking prenatal care. |
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What are screening stategies for CF?
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SCREENING STRATEGIES — Ideally, all testing within a family is performed at the same laboratory [2]. The laboratory requisition should have information about the indication for testing, racial/ethnic background, and pertinent family history (including known familial mutations) [2].
The least expensive, and probably the most widely used, strategy is to test only the woman. Her risk of having an affected child can be calculated using her risk derived from testing and, if her partner is of Northern European heritage, assuming that he has a 1 in 25 risk (background risk) of being a carrier. Some patients will be reassured by this analysis and will not request further testing, especially if the only goal of testing is to determine the risk to the fetus. The next least expensive strategy is to test the woman's partner only if her test is positive, and if she desires a more accurate prediction of her child's risk than can be obtained using the partner's background risk (as described above). This is called serial screening. The most expensive, but most accurate, method is to test both members of the couple at the same time. This is called couple screening. This method works well for those who want the most accurate risk assessment, for couples who need to know their carrier status rapidly and cannot wait for serial screening, and for those whose goal is to identify families at risk (eg, to determine whether siblings of each partner might be at risk). |
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How do you counsel a patient c patient positive or negative screening for CF?
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Positive screen — If the CF screen is positive, the individual should receive genetic counseling. If both partners carry a CF mutation, there is a one in four chance that their child will be affected. The severity of clinical disease in offspring varies as a function of the specific genetic mutations present; for CF mutations other than ΔF508 or W1282X (which are associated with classic CF), there is no simple, predictable relationship between genotype and phenotype.
Negative screen — A negative screening test means only that the individual does not carry any of the CF mutations in the screening battery; a negative result thus reduces the likelihood BUT DOES NOT ELIMINATE the possibility that the individual is a CF carrier. |
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What is dexamethasone supression test?
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Overnight 1 mg test — The overnight test consists of administration of 1.0 mg of dexamethasone at 11 PM to 12 AM, and measurement of serum cortisol at 8 AM the next morning. Using current specific immunoassays, most normal individuals have an 8 AM serum cortisol value of less than 2 mcg/dL (55 nmol/L)
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How do Cushings present how Dx?
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Cushings non specific obesity, HTN, menstral irregularity, glucose intolerance. Dx low dose dexamethasone supression test (given night) check in am. Overnight 1 mg test — The overnight test consists of administration of 1.0 mg of dexamethasone at 11 PM to 12 AM, and measurement of serum cortisol at 8 AM the next morning. Using current specific immunoassays, most normal individuals have an 8 AM serum cortisol value of less than 2 mcg/dL (55 nmol/L)
Other test 24hr cortisol urinary normal 20-25mg/kg 3x elevation suggests cushings syndrome. Now r/o adnenal tumors |
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What signs or symptoms cushings syndrome (% noted in answer)?
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Centripetal obesity 79-97
Facial plethora 50-94 Glucose intolerance 39-90 Weakness, proximal myopathy 29-90 Hypertension 74-87 Psychological changes 31-86 Easy bruisability 23-84 Hirsutism 64-81 Oligomenorrhea or amenorrhea 55-80 Impotence 55-80 Acne, oily skin 26-80 Abdominal striae 51-71 Ankle edema 28-60 Backache, vertebral collapse, fracture 40-50 Polydipsia, polyuria 25-44 Renal calculi 15-19 Hyperpigmentation 4-16 Headache 0-47 Exophthalmos 0-33 Tinea versicolor infection 0-30 Abdominal pain |
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What is typical appearance of Cushings syndrome?
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The most common feature of patients with Cushing's syndrome is progressive central (centripetal) obesity (picture 1), usually involving the face, neck, trunk, abdomen (picture 2) and, internally, spinal canal and mediastinum. Purple striae occur as the fragile skin stretches due to the enlarging trunk, breasts, and abdomen Hyperpigmentation is induced by increased ACTH, not cortisol, secretion. ACTH is the principal pigmentary hormone in humans. It acts via binding to melanocyte-stimulating hormone receptors
Osteoporosis is common in patients with Cushing's syndrome Signs of androgen excess in Cushing's syndrome are most common in women with adrenal carcinomas |
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What is the MOA of Spironolactone. What used for? What OCP avoid?
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competes with aldosterone for receptor sites in the distal renal tubules increasing sodium chloride and water extretion while conserving potasium.
Hirsiutism, Edema, Acne Heart Failure, HTN 25mg-200/day. Gynecomastia, GI anorexia, Hepatic/Renal toxoicities Drospirenone: May enhance the hyperkalemic effect of Potassium-Sparing Diuretics |
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What does quad test show on those affected by trisomy 21?
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The quadruple test involves measurement of the serum markers alpha-fetoprotein (AFP), unconjugated estriol (uE3), human chorionic gonadotropin (hCG), and inhibin A in maternal serum, ideally at 15 to 18 weeks of gestation. Maternal serum AFP and uE3 levels are, on average, reduced by 25 percent in pregnancies affected by Down syndrome [3-7], and hCG and inhibin A levels are, on average, twice as high as those in unaffected pregnancies
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What are first trimester screen?
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FIRST TRIMESTER COMBINED TEST — There are obvious advantages to performing Down syndrome screening early in pregnancy. Early diagnosis of fetal abnormalities allows the couple maximum time for decision making; privacy, since others may not be aware of the pregnancy; and, if chosen, safer methods of pregnancy termination.
First trimester Down syndrome screening is optimally done in the late first trimester, between 9 and 13 weeks of gestation, depending on which markers are used [1]. The first trimester screening test consists of three markers [2,3]: Maternal serum beta human chorionic gonadotropin (beta-hCG) Maternal serum pregnancy-associated plasma protein-A (PAPP-A) Ultrasound measurement of nuchal translucency (NT) These three markers comprise the "combined test" and are interpreted in context of the maternal age specific risk [4-6]. The combined test detects approximately 85 percent of Down syndrome (ie, detection rate [DR] = sensitivity = 85 percent) with a false positive rate (FPR) of 5 percent [3,7-16]. As described below, it can also detect trisomy 18 (table 2) (see 'Trisomy 18 risk assessment' below). The combined test performs slightly better than the second trimester quadruple test (ie, the DR is higher and the FPR is lower) (table 3). The higher DR of the combined test persists even after adjustment for the expected natural losses of Down syndrome fetuses between the first and second trimester [17,18]. A hypothetical model showed that the combined test was more cost effective (screening plus liveborn costs) than the quadruple test [19]. However, its cost effectiveness was highly dependent upon ultrasound charges and was markedly reduced if the charge for the ultrasound component of the test was high [17]. |
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What is an integrated test?
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INTEGRATED TESTS — Integrated testing uses markers measured in both the first and second trimesters to determine a single estimate of risk for Down syndrome pregnancy. In the first trimester, a serum sample is assayed for PAPP-A between 9 and 13 weeks and an ultrasound measurement of NT is performed between 10 and 13 weeks, as well as estimation of gestational age by crown-rump length. The information is kept on file until a second trimester serum sample is drawn and the quadruple test markers are run (alpha fetoprotein [AFP], unconjugated estriol [uE3], inhibin A, hCG) (table 1). Total beta-hCG can be used as a marker in either the first or second trimester. SInce it performs better in the second trimester than the first trimester, it is drawn with the second trimester markers, when possible.
The six marker values are used, together with maternal age, to calculate a single risk for Down syndrome and a report is generated. The integrated test achieves an 85 percent DR at a 1 percent FPR. If a 90 percent DR is the target, the FPR will be 2 percent |
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What is Step-wise sequential screening ?
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Step-wise sequential screening — The step-wise sequential screening process involves performing the first trimester portion of the integrated screen and then offering counseling and chorionic villus sampling (CVS) to women whose results place them at very high risk (eg, ≥1 in 50) of an affected fetus. Women whose screen does not place them at very high risk do not receive early results and go on to complete the second trimester portion of the test. The rationale for not releasing first trimester risk results to patients in the screen negative group is that this information may lead to diagnostic testing in those not at high risk and increase the observed FPR of the step-wise sequential test.
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What is Contingent sequential screening ?
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Contingent sequential screening — Contingent sequential screening is an approach in which three groups are identified based on risk,
1) women at very high risk (eg, >1 in 50) of having a fetus with Down syndrome after first trimester testing would be offered immediate invasive prenatal diagnosis, (2) women at low risk (eg, <1 in 2000) would be provided with their risk estimate and would not undergo any additional testing, and (3) women at intermediate risk (in this example, between 1 in 50 and 1 in 2000) would have a second trimester blood draw to complete the integrated test |
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How does Us calculate fetal weight?
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SUMMARY AND RECOMMENDATIONS
Fetal weight is estimated using a combination of biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) incorporated into an equation. We suggest use of the modified Hadlock formula because its mean absolute percentage error is small and more reproducible than other formulas |
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What are average fetal weights
24wks 28wks 32 wks 36 wks |
24wks-650g
28wks- 1200g 32 wks- 2200g 36 wks-3000g |
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What is pH of amniotic fluid
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pH 7-7.3
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What are risks PPROM?
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cord accidents, abruption, chorioamnitis, fetal malpresentation, pulmonary hypoplasia, septicemia, endometritis
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What is Amnisure?
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AmniSure is a rapid slide test that uses immunochromatographic methods to detect trace amounts of placental alpha microglobulin-1 protein in vaginal fluid.
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In equivicol PPROM what can you do?
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Indigo carmine 1ml in 9ml amniocentesis tampon in vaginal blue positive test
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Where place accessory trocars?
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Transilluminate 8cm lateral and 5cm above pubic sympsis transilliminate superfical epigastrics.
Fascial closure device/ foley catheter, open incion hemostasis |
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What is management PPROM depend on?
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The management of pregnancies complicated by PPROM is based upon consideration of several factors, which are assessed upon presentation:
Gestational age Availability of neonatal intensive care Presence or absence of maternal/fetal infection Presence or absence of labor Fetal presentation (Breech and transverse lies are unstable and may increase the risk for cord prolapse) Fetal heart rate (FHR) tracing pattern Likelihood of fetal lung maturity Cervical status (by visual, not digital, inspection unless induction is planned or the woman is in labor) |
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How do you counsel patient with primary HSV and PPROM?
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In light of the risk of fetal transmission during primary infection [6] and the high risk of neonatal morbidity/mortality in infected fetuses, some experts suggest prompt cesarean delivery of pregnancies as early as 28 weeks of gestation in an attempt to minimize the risk of fetal infection. The neonate is treated with acyclovir and surfactant.
Because of the significant risks of morbidity and mortality due to premature delivery in infants born at less than 32 weeks of gestation, other experts suggest avoiding delivery and giving antenatal glucocorticoids and acyclovir. Although there is a risk of HSV transmission to the fetus with this approach, the magnitude of this risk is unclear and may be small compared with the benefits of further fetal growth and development. However, the majority of pregnant women with PPROM deliver preterm and within one week of membrane rupture due to premature labor or pregnancy complications (eg, abruption, chorioamnionitis). Before 28 weeks of gestation, the risks of prematurity are very high and probably outweigh the risk of fetal infection with expectant management. Acyclovir and antenatal glucocorticoids should be given. Independent of the strategy chosen, intravenous acyclovir should be administered to the mother to shorten the time of lesions and reduce viral shedding, although there are no data showing prevention of neonatal infection. The possible role of cesarean delivery in such women is discussed below. recommendations from the CDC and the American College of Obstetricians and Gynecologists that cesarean delivery should be offered as soon as possible to women who have active lesions or, in those with a history of genital herpes or prodromal symptoms at the time of delivery [31,36]. If the membranes have been ruptured for more than six hours, a cesarean delivery should still be performed, although the benefit is not clearly proven |
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Diagnosis Syphillis stages, treatment
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Caused spirochete Treponema pallidum (flagella) Dx darkfield microscopy or visualiztion treponemes direct flurcent Ab tests
Primary Chancre round/elong ulcer 1-2 cm base clear s exudate painless Secondary sytemic flu-like/myalgias condlyoma lata-other alopecia, hepatitis, glomerularnephritis, meningitis Latent early (less 1yr) Latent late (greater 1 yr) * Teritary gumma (nodular lesions) Pregnancy infection findings Mab, stillbirth, fetal growth restriction, US hepatomegaly, splenomegaly, acites, polyhydraminos, placental thickeneing, hydrops. fetus anemia, hepatomegaly, rhinitis, CNS, thrombocytopenia later hutchinson teeth, saber shins, saddle nose, CN palsy, MR, seizures, interstital keratitis *Screening RPR (rapid plasma reagent) VDRL (Veneral disease research laboratory test)tests use cardiolipin Ag *Confirmataion TPA (Treponemal antibody absorption)-agglutination test **PE vulva, vagina, cervix, perianal, mouth, adenopathy latent syphillis evaluated tertiary disease aortisis, guma or if HIV, Tx failure CNS/eye test CSF Tx: SE Jarish-Herxheimer reaction: fevers chills myalgias HA, tachy, hyperventiiation, hypotension Tx NSAIDS **Primary , Secondary early latent Benzathine PCN G 2.4 million units IM x1 **Late latent, unknown duration Benzathine PCN G 2.4 million units IM x1 weekly x 3 weeks ** Neurosyphillis Aqueous cystalline PCN G 3-4 million units IV q 4 hrs or 18-24 million units daily cont infuaion 10-14 days |
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PCN desentization in pregnancy for syphillis
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Prior to beginning desensitization
Transfer the patient to an ICU or intermediate care unit so that a physician is immediately available at all times to evaluate the patient for any reaction (eg, wheeze, hives, change in vital signs). Patients should be evaluated before each sequential dose of antibiotic is administered. Monitor and record vital signs every 15 minutes. Monitor peak flows between doses in patients with bronchospastic lung disease. Provide adequate intravenous (IV) access (preferably 2 IVs 16 gauge or larger). Optimize the patient's hemodynamic status and avoid use of beta-blockers. Ensure that epinephrine, IV diphenhydramine, and methylprednisolone are at the bedside. Equipment and drugs for tracheal intubation should be readily accessible. Obtain informed consent from the patient or appropriate surrogate decision maker. Do not premedicate the patient with antihistamines or steroids. Preparation of dilutions After the specific antibiotic (eg, ceftriaxone 1 gram) is decided upon and the desired final dose is calculated, serial 10-fold dilutions of that dose in 50 mL of normal saline should be made: Dilution #1: 1 x 10-6 concentration of the final dose in 50 mL normal saline Dilution #2: 1 x 10-5 concentration of the final dose in 50 mL normal saline Dilution #3: 1 x 10-4 concentration of the final dose in 50 mL normal saline Dilution #4: 1 x 10-3 concentration of the final dose in 50 mL normal saline Dilution #5: 1 x 10-2 concentration of the final dose in 50 mL normal saline Dilution #6: 1 x 10-1 concentration of the final dose in 50 mL normal saline Dilution #7: Full strength final dose Administration of dilutions 50 mL of each dilution, starting with Dilution #1, should be administered intravenously over 20 minutes. Following the completion of the dose, the patient should be observed for 15 minutes and be evaluated by a physician. If no reaction has occurred, the next dose can be given in the same manner. If a reaction occurred, mod-severe Epinephrine can be repeated every 15 minutes if required. If the reaction is severe, 0.5-1.0 mg of 1:10,000 epinephrine can be given IV every 5 minutes. |
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HBV antigens and infectivity
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HBsAg appears in serum 1 to 10 weeks after an acute exposure to HBV
Anti-HBc IgM acute infec up to 2 yrs Anti- HBcIgG persists c anti-HBs recover acute HBV HBeAg- secretory protein marker HBV replectation and infectivity acute hepatitis B is based upon the detection of HBsAg and IgM anti-HBc HBsAg-positive, mom fetus HBIG as soon as possible, but within seven days of birth, and subsequently vaccinated IgM positive core- acute infection |
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HBV treatment in pregnancy
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The major problem for women who are chronic carriers of hepatitis B is the risk of maternal to infant (vertical) transmission at delivery due to exposure to maternal blood in the birth canal. Perinatal transmission of HBV is a major problem in endemic areas. Transmission at birth is more likely if the mother is hepatitis B e antigen (HBeAg) positive or has high circulating levels of hepatitis B virus DNA (HBV DNA). Prenatal screening of all pregnant women for HBsAg is now performed routinely. All neonates born to HBsAg positive women should receive HBIG and vaccine at birth. (See "Hepatitis B virus vaccination".) As a result of these measures, the incidence of perinatal transmission is declining but remains high in countries with endemic infection. Support exposure vaccine OK, expectant
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HCV Tx in pregnancy
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No effective interventions have been identified to decrease the risk of mother-to-infant transmission of HCV. Thus, no current recommendations to screen women for HCV either before or during pregnancy exist. However, infants of women known to be infected with HCV should be evaluated after 18 months of age, when maternal antibodies transferred through the placenta will no longer confound the results of serological testing [78]. Infants identified with HCV should be followed and screened periodically for chronic hepatitis. Ribavarin/ Interferon not preganct c elevate tansaminases elevated LFTs
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Doppler studies what are terms
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Doppler velocimetry of the umbilical artery (UA) provides a noninvasive measure of the fetoplacental hemodynamic state.The end-diastolic component of the Doppler waveform is crucial for assessing fetal well-being. Absence of end-diastolic flow velocity (AEDV) (figure 7) or reversal of end-diastolic flow velocity (REDV) is associated with markedly adverse perinatal outcome, particularly a high perinatal mortality rate
****Fetal karyotyping is suggested if FGR is early (<32 weeks), severe (<3rd percentile), or accompanied by polyhydramnios (suggestive of trisomy 18) or structural anomalies |
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What are indications for operative vaginal delivery
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Prolonged second stage:
Nulliparous women: lack of continuing progress for 3 hours with regional anesthesia, or 2 hours without regional anesthesia Multiparous women: lack of continuing progress for 2 hours with regional anesthesia, or 1 hour without regional anesthesia Suspicion of immediate or potential fetal compromise. Shortening of the second stage for maternal benefit |
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What are Criteria for Types of Forceps Deliveries
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Outlet forceps
Scalp is visible at the introitus without separating labia. Fetal skull has reached pelvic floor. Sagittal suture is in anteroposterior diameter or right or left occiput anterior or posterior position. Fetal head is at or on perineum. Rotation does not exceed 45º. Low forceps Leading point of fetal skull is at station >= +2 cm and not on the pelvic floor. Rotation is 45º or less (left or right occiput anterior to occiput anterior, or left or right occiput posterior to occiput posterior). Rotation is greater than 45º. Midforceps Station is above +2 cm but head is engaged. High forceps Not included in classification |
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Thalasemias how to screen
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CBC first
Determination of mean corpuscular volume (MCV) is recommended for patients who are at risk for a or b thalassemia. Patients who have a low MCV (less than 80 fL) may have one of the thalassemia traits and are candidates for hemoglobin electrophoresis. These individuals also may have iron deficiency anemia, and measurement of serum ferretin levels is recommended. Beta-thalassemia is associated with elevated Hb F and elevated Hb A2 levels (more than 3.5%). Neither hemoglobin electrophoresis nor solubility testing can identify individuals with a-thalassemia trait; only molecular genetic testing can identify this condition. If the MCV is below normal, iron deficiency anemia has been excluded, and the hemoglobin electrophoresis is not consistent with b-thalassemia trait (ie, there is no elevation of Hb A2 or Hb F), then DNA-based testing should be used to detect alpha globin gene deletions characteristic of alpha- thalassemia. |
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What is position defined as
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Position: the relationship of the fetal presenting part to the maternal pelvis. In a cephalic presentation the designated point is the occiput, while in a breech presentation it is the sacrum. The position always is described in relation to the maternal left and right sides of the pelvis.
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What is presentation?
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Presentation: the relationship between the leading fetal part and the maternal pelvic inlet. The fetus may have a cephalic, breech, or shoulder presentation
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What is lie?
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Lie: the relationship between the fetal and maternal longitudinal axes, which may be longitudinal, oblique, or transverse.
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What is Engagement?
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Engagement: the relationship that is present when the widest diameter of the fetal presenting part (biparietal diameter in a cephalic presentation, and bitrochanteric diameter in a breech presentation) has passed beyond the plane of the maternal pelvic brim. In a cephalic presentation the head usually is engaged when the leading point of the skull is at or below the maternal ischial spines.
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What is asynclitism?
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Asynclitism: the relationship between the anterior and posterior parietal bones and the sagittal suture with the maternal pelvis. When neither of the parietal bones precedes the sagittal suture, the head is synclitic; if the anterior parietal bone precedes the sagittal suture, there is anterior asynclitism; and when the posterior parietal bone precedes the sagittal suture, there is posterior asynclitism
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What is clinical pelvimetry?
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Clinical Pelvimetry: assessment of the maternal pelvis before performing midpelvic delivery.
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What are complications of vacuum delivery?
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The vacuum cup can cause scalp lacerations if torsion is excessive. In addition, separation of the scalp from the underlying structures can lead to cephalohematoma, which is more common in infants delivered by vacuum extractor (14–16%) than in those delivered with forceps (2%) (6, 7). The incidence of subgaleal hematomas (collections of blood occurring in the potential space between the cranial periosteum and the epicranial aponeurosis) following vacuum deliveries is estimated to range from 26 to 45 per 1,000 vacuum deliveries (14, 15).
Other potential neonatal complications associated with vacuum deliveries include intracranial hemorrhage, hyperbilirubinemia, and retinal hemorrhage. The higher rates of neonatal jaundice associated with vacuum delivery may be related to the higher rate of cephalohematoma (16). There is a higher rate of retinal hemorrhages (38%) with vacuum delivery than with forceps delivery (17%) (6, 7, 17, 18). However, corneal abrasions and external ocular trauma are more common with forceps delivery than with normal spontaneous delivery and are rare with vacuum extraction unless the cup is inadvertently placed over the eye. |
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What are contraindications to operative vaginal delivery?
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inappropriate in pregnancies before 34 weeks of gestation because of the risk of fetal intraventricular hemorrhage. Operative delivery also is contraindicated if a live fetus is known to have a bone demineralization condition (eg, osteogenesis imperfecta), a bleeding disorder (eg, alloimmune thrombocytopenia, hemophilia, or von Willebrand's disease) is present, the fetal head is unengaged, or the position of the fetal head is unknown.
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What are risk factors for IUGR
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Maternal medical conditions
Hypertension Renal disease Restrictive lung disease Diabetes (with microvascular disease) Cyanotic heart disease Antiphospholipid syndrome Collagen-vascular disease Hemoglobinopathies Smoking and substance use and abuse Severe malnutrition Primary placental disease Multiple gestation Infections (viral, protozoal) Genetic disorders Exposure to teratogens |
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How does smoking affect pregnancy?
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Women who smoke have a 3.5-fold increase of SGA infants, compared with nonsmokers. Newborns of smokers are smaller at every gestational age. Women who stop smoking before 16 weeks of gestation have infants with birth weights similar to those of babies of women who never smoked , and women who quit as late as the seventh month have mean birth weights higher than those who smoked during the entire pregnancy
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What drugs cause IUGR?
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The incidence of IUGR is markedly increased in pregnant women who use illicit drugs, but it is difficult to differentiate the drug effect from the effects of other behaviors associated with drug use. The incidence of SGA infants in mothers with heroin addiction is as high as 50% and is reported to be as high as 35% in patients managed with methadone. Cocaine abuse in pregnancy is associated with delivery of an SGA neonate in 30% or more of cases
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What placenta findings cause IUGR?
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Primary placental disease (such as chorioangioma) is a rare but recognized cause of growth restriction. Placenta previa has been associated with an increase in growth restriction, presumably secondary to abnormal placental implantation. Confined placental mosaicism has been identified three times more frequently from placentas of SGA infants than in infants of normal growth
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What infections cause growth restriction?
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Viral infections have been estimated to be etiologic in less than 5% of all growth-restricted fetuses. However, when evaluated in documented cases of in utero viral infection, the frequency of IUGR can be strikingly high. Fetal rubella infection is associated with growth restriction in up to 60% of cases. Cytomegalovirus also is a recognized cause of growth restriction. In one study, approximately 40% of fetuses with varicella syndrome exhibited growth restriction. Bacterial infections have not been shown to cause growth restriction. Some protozoal infections, such as Toxoplasma gondii, Trypanosoma cruzi (Chagas disease), and syphilis, are associated with growth restriction
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What medications cause IUGR
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Therapeutic agents known to be associated with growth restriction include anticonvulsants (eg, trimethadione, phenytoin), folic acid antagonists (eg, methotrexate) , and warfarin
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What are neonatal complications in the SGA infant?
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Neonatal complications in the SGA infant include polycythemia, hyperbilirubinemia, hypoglycemia, hypothermia, and apneic episodes, as well as low Apgar scores, umbilical artery pH less than 7.0, need for intubation in the delivery room, seizures, sepsis, and neonatal death
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What are long term follow up of SGA infants?
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Long-term follow-up of infants with SGA shows that they are more prone to develop adult-onset hypertension and cardiovascular complications
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What is the two essential steps involved in the antenatal recognition of growth restriction?
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There are two essential steps involved in the antenatal recognition of growth restriction. The first step involves the elucidation of maternal risk factors associated with growth restriction and the clinical assessment of uterine size in relation to gestational age. The second step involves the ultrasonographic assessment of fetal size and growth, supplemented by invasive fetal testing for aneuploidy or viral infection in select cases.
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Clotting factors that decrease in pregnancy
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11,13
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Premarin, dosing and MOA?
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Menopause (moderate-to-severe vasomotor symptoms): Oral: Initial: 0.3 mg/day. May be given cyclically* or daily, depending on medical assessment of patient. The lowest dose that will control symptoms should be used. Medication should be discontinued as soon as possible.
Vulvar and vaginal atrophy: Oral: Initial: 0.3 mg/day. The lowest dose that will control symptoms should be used. May be given cyclically* or daily, depending on medical assessment of patient. Medication should be discontinued as soon as possible. Vaginal cream: Intravaginal: 0.5-2 g/day given cyclically* Abnormal uterine bleeding: Acute/heavy bleeding: Oral (unlabeled route): 1.25 mg, may repeat every 4 hours for 24 hours, followed by 1.25 mg once daily for 7-10 days I.M., I.V.: 25 mg, may repeat in 6-12 hours if needed MOA: Estrogens also affect the release of pituitary gonadotropins. The pharmacologic effects of conjugated estrogens are similar to those of endogenous estrogens. Conjugated estrogens, a mixture of the water soluble salts of sulfate esters from estrone, equilin, 17 α-dihydroequilin, and other related steroids, may be derived from pregnant equine urine or yam and soy plants. Estrogens are important in the development and maintenance of the female reproductive system and secondary sex characteristics. They promote growth and development of the vagina, uterus, and fallopian tubes, and enlargement of the breasts. Indirectly, they contribute to the shaping of the skeleton, maintenance of tone and elasticity of urogenital structures, changes in the epiphyses of the long bones that allow for the pubertal growth spurt and its termination, growth of axillary and pubic hair, and pigmentation of the nipples and genitals. |
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Most likely cause death in 50yo, 65yo
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malignant neoplasms, cardiovascular disease
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What are four standard fetal measurements generally are obtained as part of any complete obstetric ultrasound?
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Four standard fetal measurements generally are obtained as part of any complete obstetric ultrasound examination after the first trimester: 1) fetal abdominal circumference, 2) head circumference, 3) biparietal diameter, and 4) femur length
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What is abdominal circumference in relation to IUGR?
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An abdominal circumference within the normal range reliably excludes growth restriction with a false-negative rate of less than 10% (71). A small abdominal circumference or fetal weight estimate below the 10th percentile suggests the possibility of growth restriction, with the likelihood increasing as the percentile rank decreases
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What is accuracy of Fundal heigh and US in detecting growth restricted fetus?
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In essence, all pregnancies are screened for IUGR using serial fundal height measurements. A single measurement at 32-34 weeks of gestation is approximately 70-85% sensitive and 96% specific for detecting the growth-restricted fetus (82). A third-trimester ultrasound examination, with a single measurement of abdominal circumference, detects about 80% of IUGR fetuses (70). Even so, this does not justify ultrasonography as a screening tool, because fundal height measurement performs comparably (70). All pregnancies should be screened with serial fundal height assessments, reserving ultrasonography for those with risk factors, lagging growth, or no growth
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What are the best ways to evaluate and monitor a pregnancy complicated by suspected intrauterine growth restriction?
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Once IUGR is suspected (ie, lagging fundal height), it should be confirmed using multiple ultrasonographic parameters, such as estimated weight percentile, amniotic fluid volume, elevated head circumference and abdominal circumference ratio, and possibly Doppler criteria (ie, elevated systolic-diastolic ratio or reversed or absent end-diastolic flow) (85). Identification of IUGR is improved by recording growth velocity or through two sets of examinations generally 2-4 weeks apart.
The diagnosis of IUGR as the fetus approaches term may be an indication for delivery (86). If pregnancy is remote from term or if delivery is not elected, the optimal mode of monitoring has not been established. Periodic fetal assessment (approximately weekly) using Doppler velocimetry, contraction stress test, traditional biophysical profile (BPP), modified BPP, or nonstress test (NST) are all accepted monitoring techniques. Randomized controlled trials have demonstrated that monitoring with Doppler velocimetry reduces the risk of perinatal morbidity (81). Comparable studies for the other methods have not been done. Serial ultrasonograms to determine the rate of growth should be obtained approximately every 2-4 weeks. Measurements at shorter intervals (<2 weeks) may overlap with measurement errors. If any test result is abnormal (decreased amniotic fluid volume or low BPP scores), more frequent testing, possibly daily, may be indicated. An abnormal result from fetal heart rate testing (decreased variability) coupled with abnormal results from Doppler velocimetry suggests poor fetal well-being and a potential need for delivery, despite prematurity |
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How are doppler studies helpful in IUGR?
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Doppler ultrasound has been shown to be useful in the assessment of the growth-restricted fetus (104). Absent or reversed end-diastolic flow velocities in the umbilical arteries have a poor positive predictive value but are associated with poor perinatal outcome and high perinatal mortality (105-107). In contrast, a normal systolic-diastolic ratio in a growth-restricted fetus has excellent negative predictive value and may be used as a rationale to delay delivery with some reassurance. Currently, there are not enough data to warrant cordocentesis in the management of IUGR.
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How does knowledge of the etiology of intrauterine growth restriction alter management?
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A detailed ultrasound survey should be performed to detect fetal structural defects. Fetal karyotype determinations are not routinely indicated in the assessment of growth-restricted fetuses, but should be considered when early or severe IUGR is detected or when the fetus has a recognized structural anomaly. It is estimated that about 10% of structurally abnormal fetuses with fetal growth restriction will have a karyotype anomaly.
Prenatal diagnosis of in utero infections also can be accomplished via amniotic fluid or fetal blood analyses. Viral infections associated with IUGR, such as rubella, cytomegalovirus, or varicella, can be diagnosed by polymerase chain reaction or by measuring viral-specific immunoglobulin M antibodies. There are, however, no in utero treatments for these infections. However, if toxoplasmosis is identified, medication taken by the mother may prevent the spread of maternal infection to the fetus |
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When should a growth-restricted fetus be delivered?
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The fetus should be delivered if the risk of fetal death exceeds that of neonatal death, although in many cases these risks are difficult to assess. The timing of delivery in the growth-restricted fetus should be individualized. Early delivery may yield an infant with all the serious sequelae of prematurity, whereas delaying delivery may yield a hypoxic, acidotic infant with long-term neurologic sequelae. Gestational age and the findings of antenatal surveillance should be taken into account. The decision to deliver is based often on nonreassuring fetal assessment or a complete cessation of fetal growth assessed ultrasonographically over a 2-4-week interval. When extrauterine survival is likely despite significantly abnormal antenatal testing, delivery should be seriously considered.
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What are causes of annovulation?
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Physiologic
Adolescence Perimenopause Lactation Pregnancy Pathologic Hyperandrogenic anovulation (eg, polycystic ovary syndrome, congenital adrenal hyperplasia, androgen-producing tumors) Hypothalamic dysfunction (eg, secondary to anorexia nervosa) Hyperprolactinemia Hypothyroidism Primary pituitary disease Premature ovarian failure Iatrogenic (eg, secondary to radiation or chemotherapy) |
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What is DDX of noncylic uterine bleeding?
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Differential Diagnosis of
Noncyclic Uterine Bleeding Anovulation Uterine leiomyoma Endometrial polyp Endometrial hyperplasia or carcinoma Cervical or vaginal neoplasia Endometritis Adenomyosis Bleeding associated with pregnancy threatened or incomplete abortion trophoblastic disease ectopic pregnancy Bleeding associated with the puerperium retained products of conception placental polyp subinvolution of the uterus Coagulopathies (von Willebrand's disease, platelet abnormalities, thrombocytopenic purpura) Iatrogenic causes and medications Systemic diseases |
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What is role high dose estrogen theraphy in controlling acute bleeding?
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Women who experience acute, profuse anovulatory bleeding are candidates for estrogen therapy. In approximately 90% of cases, acute bleeding does not require surgical intervention, but it can be treated with medical therapy (8). In a large series of 61 adolescents (mean age, 13.8 ± 2.1 years) with acute anovulatory uterine bleeding, only five (8.2%) failed medical therapy and required dilation and curettage to stop their bleeding. Conjugated equine estrogen therapy can be administered intravenously (25 mg every 4 hours for 24 hours). However, oral conjugated estrogen therapy at 10–20 mg per day in four divided doses can be substituted for intravenous estrogen administration. In a randomized trial of intravenous conjugated equine estrogen therapy versus placebo, conjugated estrogens were effective in stopping vaginal bleeding in a significantly greater proportion of women (72%) than those who received a placebo (38%) (13). Although this study included women with biopsy-proven pathology, it is one of the few studies performed to assess the efficacy of intravenous estrogen therapy for the treatment of women with anovulatory uterine bleeding. Patients who do not respond to 1–2 doses of estrogen with a significant decline in blood loss or are not hemodynamically stable should undergo dilation and curettage. Furthermore, as high-dose estrogen therapy is commonly associated with nausea, concomitant medical therapy with antiemetics should be considered.
After the acute episode of bleeding has been controlled, amenorrhea should be maintained for several weeks to allow for resolution of anemia. The best method of therapy is a combination oral contraceptive. To extend the interval before the next menses, continuous oral contraceptives (without the use of placebo pills) can be given for several months; however, over time the patient will be susceptible again to breakthrough bleeding. Once the patient's anemia has resolved, cyclic oral contraceptives can be prescribed. All anemic patients should be given iron therapy |
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What are treatments for annovulatory bleeding?
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The treatment of choice for anovulatory uterine bleeding is medical therapy with oral contraceptives. Cyclic progestins also are effective.
Women who have failed medical therapy and no longer desire future childbearing are candidates for endometrial ablation, which appears to be an efficient and cost-effective alternative treatment to hysterectomy for anovulatory uterine bleeding. However, endometrial ablation may not be definitive therapy. |
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Largest diameter of fetal head
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mentum supraoccipital 12.5 cm
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What is brow presentation
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clinically ability palpate brow and saddle of nose and orbits. US hyperextended fetal neck. Face is exclude because chin and mouth not palpable.
Face and brow presentations are associated with multiparity, cephalopelvic disproportion, and fetal anomalies (eg, anencephaly, anterior neck mass). In the face presentation with the mentum anterior or transverse, we suggest that labor be allowed to progress. Augmentation may be used in setting of a normal fetus and abnormally slow progress as long as the fetal heart rate pattern remains reassuring. The face presentation with persistent mentum posterior will not deliver vaginally, therefore abdominal delivery is indicated. We suggest continuous intrapartum fetal heart rate monitoring for malpresenting fetuses as there is an increased risk of nonreassuring patterns with malpresentations. Fifty percent of brow presentations will spontaneously convert to a face or vertex presentation. Therefore, we suggest that labor be allowed to progress, with careful monitoring and delivery by cesarean when an arrest of progress is diagnosed. There is an increased risk for fetal trauma (face, cervical spine, trachea, or small parts) with face presentations. |
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How is a vacuum placed?
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over sagital suture 3 cm in front posterior fontenelle. The cup should be applied at the flexion point and the edges swept with a finger to insure that no maternal tissues are entrapped. In the normally molded fetal head, the flexion point is in the midline, over the sagittal suture, approximately 6 cm from the anterior fontanelle and 3 cm from the posterior fontanelle
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Hgba1c 8 equals
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180
every additional unit is 30dl/ml ie hgbA1c=9 180+30=210 |
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How to delivery nucal arm in a breech delivery
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If the arms do not deliver spontaneously, intervention will be required. The baby is held by the hips or bony pelvis, never by the abdomen, as injury to the kidneys/adrenals is possible. We wrap the legs/pelvis in a towel to provide a good grip and keep the back upwards. The baby is rotated through 180 degrees to deliver the first shoulder and arm, then in the opposite direction so the other shoulder and arm deliver under the symphysis pubis (figure 2A-B). The second rotation may be assisted by gentle traction on the delivered arm in the direction of the rotation.
Failure of the shoulders and arms to deliver with simple rotation of the trunk is dealt with by sliding an index finger along the baby's scapula, over the shoulder, and into the antecubital fossa. The elbow is then swept in front of the baby's face and downward to the chest, at which point the arm can be delivered (figure 1C). This procedure is repeated for the other side. Gentle rotation of the fetal trunk at the same time, keeping the back anterior (ie, toward the ceiling), will assist this maneuver. If the arms remain trapped behind the neck, the fetus can be rotated so the chest is facing the symphysis pubis. This helps to dislodge the nuchal arm(s) and allows the elbow to be swept down and extracted, as described above. Arm extraction can cause shoulder dislocation or broken bones, but these complications are less morbid than prolonged dystocia resulting in asphyxia. |
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Fetal head entrapment how to avoid?
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uterine relaxant, Druushen incions 10, 2 and 6 o'clock, nitroglycerin, magnesium.
At this stage, the baby's head may start to appear without any further effort on the operator's part. If the hairline is not visible after the shoulders have delivered, the baby's body is turned to face the floor and suprapubic pressure is applied by an assistant to flex the head and push it down into the pelvis (Bracht maneuver) (figure 3). Once the hairline is visible, the head is delivered. We prefer to use forceps for delivery of the aftercoming head. If forceps delivery is not possible or desired, the fetus' legs are swung upwards, keeping the vulva completely covered with the operator's other hand to keep the head from "popping." This hand is then opened slowly to allow first the baby's face and then the remainder of the head to deliver with maternal expulsive efforts. The Mauriceau-Smellie-Veit maneuver is favored by some obstetricians for routine delivery of the head. The middle finger of one hand is placed in the mouth, and the second and fourth fingers on the malar eminences to promote flexion and descent while counter-pressure is applied to the occiput with the middle finger of the other hand. With either forceps or spontaneous delivery, it is essential that the baby's legs be kept vertically in the air, but the trunk should be no more than 45 degrees above horizontal; this avoids traction on the cervical spine during delivery of the head. If the body is bent backwards too far (eg, over the mother's abdomen), hyperextension of the neck can occlude the vertebral arteries and can lead to necrosis of the cervical cord. Excess weight on the cervical spine from downward traction can have the same effect or dislocate the baby's neck. CESAREAN BREECH DELIVERY — The abdominal and uterine incisions should be sufficiently large so no part of the baby is caught in the abdominal wound. |
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Hemabate precautions MOA
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CI Asthma, Pulmonary edema, 8 dose 250mcg q 15 min (max 2 mg)
MOA |
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How much pressure for vacuum?
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Suction pressure is measured in various units: 0.8 kg/cm2 of atmospheric pressure = 600 mmHg = 23.6 inches of Hg = 11.6 lb/in(2).
Vacuum suction pressures of 500 to 600 mmHg have been recommended during traction, although pressures in excess of 450 mmHg are rarely necessary (green zone) (picture 4) [14,15]. While lower suction pressures increase the risk of cup "pop-offs," pressures beyond 600 mmHg increase the risks of fetal scalp trauma and cerebral, cranial and scalp hemorrhage. A slow, stepwise increase in vacuum pressure was initially practiced, but is no longer deemed necessary [16]. Two trials comparing gradual (eg, over 8 to 10 minutes) versus rapid (eg, over 1 to 2 minutes) application of vacuum pressure demonstrated the rapid technique reduced the duration of the vacuum extraction procedure without compromising efficiency and safety [17,18]. The clinician also needs to keep in mind that cup sizes vary among different manufacturers' devices and that cup size affects the overall traction force applied since force = (area under the cup)(suction). Therefore, as the size of the cup increases, the total force applied will rise even with the same amount of applied suction [19]. As an example, with 600 mmHg of suction, a 50 mm cup will generate 15.7 kg of traction force while a 60 mm cup will generate 22.6 kg of traction force. Whether the greater traction forces associated with larger cup sizes are associated with higher vaginal delivery rates or more fetal morbidity is unclear. Finally, the notion that the vacuum is "designed to pop-off before damage occurs" is erroneous and should not be considered a safety mechanism. The maximum suction pressure should not exceed 600 mmHg. Exert traction — The absolute "safe" traction force for vacuum extraction is unknown. |
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How much traction on vacuum
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Traction is applied along the axis of the pelvic curve to guide the fetal vertex, led by the flexion point, through the birth canal. Initially, the angle of traction is downward (toward the floor); the higher the beginning station, the steeper the angle of downward traction required. The axis of traction is then extended upwards to a 45 degree angle to the floor as the head emerges from the pelvis and crowns. In addition, the handle of the device is allowed to passively turn as the head auto-rotates through its descent. The handle should never be actively twisted to rotate the head. This dangerous maneuver can cause "cookie cutter" injuries to the fetal scalp [3].
Traction is gradually discontinued as the contraction ends or the mother stops pushing. Between contractions, suction pressure can be fully maintained or reduced to <200 mmHg; it is well established that fetal morbidity is similar for both regimens [26]. Descent should occur with each application of traction, beginning with the first. When the head is delivered, the suction is released, the cup is removed, and the remainder of the delivery proceeds as usual. (See "Management of normal labor and delivery".) Routine episiotomy is not necessary for an assisted vaginal birth and may increase the risk of significant perineal trauma [27]. In a series of 1000 consecutive omnicup-assisted deliveries, the incidence of third and fourth degree tears with versus without an episiotomy was 15.8 and 5.8 percent, respectively [24]. |
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What are reason for vacuum failure?
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Some reasons for failure include:
Fetopelvic disproportion Incorrect technique — Pulling the stem too quickly or when maternal expulsive efforts are weak will lead to cup detachments. Moreover, upwards traction before the head is crowning will tend to disrupt the vacuum seal and lead to pop-offs. Incorrect cup size also increases the risk of failure. Paramedian or deflexing applications — It is essential to identify the flexion point and focus the vacuum traction to leading the mentovertical diameter through the pelvis. Off-midline applications or deflexing applications will pull less favorable diameters of the fetal head through the pelvis and inhibit, rather than assist, delivery [31]. Large caput succedaneum — An increase in fetal scalp edema lets more of the scalp to be drawn into the cup, which reduces the available vacuum area, and, in turn, lessens total traction. The effect is more pronounced with bell-shaped cups than in M-style cups [11], and with soft cups compared with rigid cups [10]. Failure of an attempted vacuum assisted delivery increases the likelihood of neonatal morbidity [32]; the subsequent use of sequential forceps in this setting has been associated with an increased risk of neonatal intracranial hemorrhage [33] and is rarely indicated. Prompt cesarean delivery is advised after an unsuccessful vacuum assisted procedure. |
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How do you perform Duhrssen Incisions?
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Cervix effaced completely incompletely dilated. cervical os surgically enlarged 1-2 fingers under cervix to protect fetus. Bandage incions made incision 2,6,10. full length cervical lip. Dangers ureter broad ligament extension lower uterine segment. Danger ureter bladder uterine vessels sever hemorrage.
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How deliver arms in vaginal breech?
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Lovset manuver
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DDx 7yo vaginal bleeding
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Trauma, vaginal bleeding, exogenous hormones (OCP), granulosa cell tumor, precocious puberty, sarcoma boitroydes, urethral prolapse
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36 yo DDx menorraghia
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pregnancy, fibroid, adenomyoseis, polyp, endometrial cancer hyperplasia, bleeding coagulopathy, trauma, thyroid disease, hyperprolacinemia, PCOS
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What are ways to help deliver premature breech by cesarean?
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Premature breech — The preterm lower uterine segment may be very narrow, making delivery through a transverse lower uterine incision difficult. Several solutions have been suggested:
Using a vertical uterine incision Giving halothane to relax the uterus Administering a uterine relaxant just before opening the uterus A review of 416 breeches of various gestational ages delivered by low transverse or low vertical incisions found no advantages for low vertical incisions Since this was an observational series and the patients delivered by low transverse incisions had different characteristics than those delivered by low vertical incisions, one cannot conclude that the two incisions were similarly safe and effective. Case by case clinical judgment should guide this decision. Whichever incision is used, the baby must be delivered gently and atraumatically. Forceps, if the appropriate size is available, are useful for the aftercoming head. |
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Mirena IUD type progestrone and amount released.
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Levonogetrol 52mg, 20mcg released per day
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Critera for optima breech delivery?
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Criteria for an optimal situation — Various criteria have been developed to minimize the risk of vaginal breech delivery. These criteria for patient selection are largely based upon clinical experience, and typically include [2-6]:
No contraindication to vaginal birth (eg, placenta previa, contracted pelvis, cord presentation) No prior cesarean deliveries Absence of fetal anomaly that may cause dystocia Estimated fetal weight at least 2000 to 2500 g and not more than 4000 g Gestational age 36 weeks or more No hyperextension of the fetal head (ie, an extension angle of greater than 90 degrees) Frank or complete breech presentation (incomplete breech presentation is a contraindication) Spontaneous labor Staff skilled in breech delivery and immediate availability of facilities for safe emergency cesarean delivery (eg, anesthesia, obstetrical, and pediatric personnel, surgical facilities and personnel). |
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Office 13-18yo what do in annual exam, vaccines, procedures, laboratories
leading cause death? |
Screening: Hx,PE (tanner), Laboratory:GC/CT High risk groups- hemoglobin assesment, HIV, HCV,Rubella, TB, Lipid assesment, fasting glucose, colorectal cancer.
Evaluation and counseling -sexuality - fitness and nutrition -psychosocial evaluation - cardiovascular risk factors - health/risk behaviours Immunizations -TdP (11-16) -Td -HBV -HPV -Meningoccal High risk groups (influenza HAV, Pneumococcal, MMR) |
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Office 13-18yo leading cause death?
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accidents, malignant neoplasms, homocide
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Office 13-18yo leading cause morbidity?
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acne, asthma, chlyamdia, headache, ENT, obesity, sexual assault, STD, UTI, vaginitis
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Office what are components of screening history 13-18?
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- reason visit
- health status medical, medical, menstral - surgical, family; dietary/ nutrition assesment - physical activity - use complementary and alternative methods - tobacco, ETOH, Drug use - Abuse/neglet - Sexual practices |
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Office what are components of screening history 19-39 and 40-64, 65+ what changes from 13-18?
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Urinary and fecal incontinence
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Office what are components of physical exam 13-18yrs?
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1
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Office what are components of physical exam 13-18yrs? How does this change in 19-39
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2
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Office what are components of physical exam 13-18yrs? How does this change in 19-39
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3
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Office what are components of physical exam 13-18yrs? How does this change in 19-39
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4
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What is a thecoma?Is it malignant?
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Thecomas are usually benign tumors, but some have malignant elements. Like granulosa cell tumors, thecomas may produce estrogen (table 2) and usually present as abnormal uterine bleeding in a postmenopausal woman.
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What is stage 1 of endometrial cancer?
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Stage 1 A endometrial or endocervical glands involvement or inner half myometrial invasion
Stage 1 B outer half myometrium |
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What is stage II endometrial cancer?
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Cervical stromal involvement
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What is stage 3 endometrial cancer? stage 4?
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Stage 3 a positive pelvic cytology adnexa or uterine serosa
3b vaginal or parametrial involvement 3c positive lymph nodes pelvic/paraaortic Stage 4a rectal/ bladder mucosa 4b distant mets inguinal nodes |
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What are causes of PM bleeding?
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ERT, Atrophy, Cancer (endometrium, cervix, other)
Polyps endometrial/cervix |
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What are fibromas of ovary what can they cause
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Most common sex cord stromal tumor Meigs ovarian fibroma,acites, pleural effusion
Fibromas are the most common of the sex-cord stromal tumors. Pure fibromas are benign solid tumors, usually unilateral, that primarily occur in postmenopausal women. They are not hormonally active. Cellular fibromas are characterized by mildly increased cellular density, mild nuclear atypia, and an average of three or fewer mitotic figures per 10 HPF. In contrast, fibrosarcomas (which have four or more mitotic figures per 10 HPF plus marked cellular density and nuclear atypia) are rare malignant ovarian sarcomas whose aggressiveness correlates with the number of mitoses and the degree of anaplasia. On ultrasound examination, an ovarian fibroma may appear as a mass that is either hyper- or hypoechoic, which may be calcified and/or exhibit cystic degeneration [91]. Ascites is present in 10 to 15 percent of cases and hydrothorax in 1 percent, especially with larger lesions. The association of ovarian fibroma with ascites and/or pleural effusion is termed Meigs' syndrome [92]. Fluid accumulation is probably related to substances like vascular endothelial growth factor (VEGF) that raise capillary permeability |
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What cell causes estradiol production in granulosa cell tumors?
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Theca cells, which are luteinized cells within the stroma, are present in about 70 percent of cases. Theca cells produce androstenedione, a weak androgen, and granulosa cells convert the androstenedione to estradiol. Significant hormone production is responsible for the clinical phenotype associated with the tumor.
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Granulosa stromal cell tumors consist of what?
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Granulosa thecoma fibroma
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What is difference between endometrial cancer type 1 and type 2?
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Endometrial cancer Type 1
Obesity estrogen excess arises from endometrial hyperplasia (androsteinedione converted to E1 by aromotase in adipose) CANCERS are early stage, low grade indolent cell types FAVORABLE PROGNOSIS Type 2 -Arises from endometrial atrophy -Genetic causes p53 -High grade, advanced stage agressive cell types POOR prognosis 58% 5 yr survival |
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What is mild intermittant asthma?
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Mild persistent — Mild persistent asthma is characterized by the following (table 5):
Symptoms more than twice weekly (although less than daily) Three to four nocturnal awakenings per month due to asthma Use of short-acting beta agonists to relieve symptoms more than two times a week (but not daily) Minor interference with normal activities FEV1 measurements within normal range (≥80 percent of predicted normal) FEV1/FVC ratio is normal (based on age-adjusted values) Two or more exacerbations requiring oral glucocorticoids per year If these various elements are discordant, the patient's asthma should be categorized at the level of the most severe. |
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What is moderate persistant asthma?
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Moderate persistent — The presence of any of the following is considered an indication of moderate disease severity (table 5):
Daily symptoms of asthma Nocturnal awakenings more than once per week Daily need for short-acting beta agonists for symptom relief Some limitation in normal activity FEV1 between 60 and 80 percent of predicted FEV1/FVC reduced below normal (based on age-adjusted values) Two or more exacerbations requiring oral glucocorticoids per year |
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What is severe persistant asthma?
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Severe Persistent — Patients with severe persistent asthma experience one or more of the following (table 5):
Symptoms of asthma throughout the day Nocturnal awakenings nightly Need for short-acting beta agonists for symptom relief several times per day Extreme limitation in normal activity FEV1 < 60 percent of predicted FEV1/FVC reduced below normal (based on age-adjusted values) Two or more exacerbations requiring oral glucocorticoids per year |
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Incresed risk for aneuplody
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DZ twins over 31, trisomy previously, 47XXX, 47XXY, translocation, inversion, early pregnancy loss, obesity
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Dictate a TVH
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Positioning in dorsal lithotomy is critical to obtain optimal exposure. When adequate anesthesia is obtained, a bimanual pelvic examination is performed to confirm the findings of the office examination, to assess uterine mobility and descent, and to confirm that no unsuspected adnexal pathology is found. A final decision can then be made whether to proceed with a vaginal or abdominal approach.
The patient is prepared and draped. A bladder catheter may be inserted, back filled with dilute methylene blue. A weighted speculum is placed into the posterior vagina, a Deaver or right angle retractor is positioned anterior to the cervix and then the anterior and posterior lips of the cervix are grasped with a single- or double-toothed tenaculum. Vasopressin (10 to 20 units in 50-mL saline) or lidocaine (0.5 percent) may be injected into the cervical, paracervical, and submucosal tissues to help identify tissue planes and reduce blood loss. Hysterectomy Entry — A circumferential incision in the vaginal epithelium at the junction of the cervix just below the bladder reflection dissected sharply to the underlying tissue. The exposed posterior peritoneum is then incised with a generous bite using Mayo scissors (pouch of Douglas) a figure-of-eight suture is then taken to attach the peritoneum to the posterior vaginal epithelium. A Steiner-Anvard weighted speculum is inserted into the posterior cul-de-sac after this space is opened. The uterosacral ligaments are clamped, with the tip of the clamp incorporating the lower portion of the cardinal ligaments .The clamp is placed perpendicular to the uterine axis, and the pedicle cut so that there is approximately 0.5 cm of tissue distal to the clamp. Once ligated, the uterosacral ligaments are transfixed to the posterior lateral vaginal epithelium to further support the vagina and provide hemostasis Downward traction is placed on the cervix to provide countertraction for the vaginal epithelium and the anterior vaginal epithelium is incised at the level of the cervicovaginal junction the bladder is advanced upward using an open, moistened gauze sponge vesicovaginal peritoneal is identified and entered sharply using scissors. A Heaney or Deaver retractor is placed into this space to protect the bladder and to aid visualization of the abdominal contents. Ligating the uterine vessels — The cardinal ligaments are identified, clamped, cut, and suture ligated in a manner similar to that used for the uterosacral ligaments. Constant traction directed to the contralateral side from the operative site is maintained on the cervix. If the left uterine artery is to be ligated, as an example, the uterus is directed downward and to the right. The uterine vessels are clamped in such a way as to incorporate the anterior and posterior leaves of the visceral peritoneum; a single-clamp technique is adequate and decreases the potential risk of ureteral injury. The uterine fundus is delivered posteriorly accomplished by placing a tenaculum on the uterine fundus in successive bites. The surgeon's index finger is used to identify the utero-ovarian ligament and aid in clamp placement. The remainder of the utero-ovarian ligaments are clamped and cut the pedicles are double-ligated first with a suture tie and followed by a suture ligature medial to the first tie Salpingo-oophorectomy — If the adnexa are to be removed, traction is placed on the ovary by grasping it with a Babcock clamp. A Heaney clamp is placed across the infundibulopelvic ligament and the ovary and tube are excised if the infundibulopelvic ligament is mobile and elongated. Both a suture tie and transfixion suture ligature are placed on this pedicle. A lap-strip is placed into the peritoneal cavity and each of the pedicles is visualized and inspected to ensure that hemostasis has been obtained. A continuous absorbable zero suture is begun at the 12-o'clock position and a pursestring suture is placed incorporating the distal portion of the left upper pedicle and the left uterosacral ligament. The posterior peritoneum is sutured as high as is practical;to prevent the formation of an enterocele in the future. Closure — The vaginal epithelium is reapproximated in either a vertical or horizontal manner using either a continuous suture or a series of interrupted sutures The sutures are placed through the entire thickness of the vaginal epithelium, making certain that the bladder is not entered. McCall culdoplasty (obliteration of the cul-de-sac with plication of the uterosacral-cardinal complex and elevation of any redundant posterior vaginal apex) An absorbable suture is placed through the full thickness of the posterior vaginal wall at the apex of what will be the vaginal vault. The suture is then passed through the left uterosacral ligament pedicle, the posterior peritoneum, and the right uterosacral ligament and completed by passing the suture from the inside to the outside at the same point that it was begun. The suture is then tied, which approximates the uterosacral ligaments and posterior peritoneum. A vaginal pack and bladder catheter in place. |
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SSLF nn injuries
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sacral or pudendal neuropathy
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What is prolift?
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Fix POP like TVT vesicovaginal space dissected ischial spines (ant arms), obturator foramen (post arms) polypropylene mesh is less dense and has larger pores than previous meshes, which could lead to decreases in reactive scar formation
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How treat urethra diverticulum
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Voiding cystourethrogram
Distal third diverticulum removed reapproximate urethra. Middle urethra imbricating layers Distal urethral worry about comprise urethral length- recreate urethral length. |
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What is type 1 diabetes
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type 1 pregestational diabetes mellitus is characterized by an autoimmune process that destroys the pancreatic ß cells, leading to the need for insulin therapy.
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What is congenital cretinism?
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congenital cretinism (growth failure, mental retardation, and other neuropsychologic deficits).
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KAryotype associated c stillbirth
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If an abnormal karyotype is found in association with stillbirth, the most common abnormalities are monosomy X (23%), trisomy 21 (23%), trisomy 18 (21%), and trisomy 13 (8%).
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Risk Factors that May Prompt
Anesthetic Consultation |
Anesthetic consultation may be considered when any of the following risk factors are present:
Marked obesity Severe edema or anatomical abnormalities of the face or neck or spine, including trauma or surgery Abnormal dentition, small mandible, or difficulty opening the mouth Extremely short stature, short neck, or arthritis of the neck Goiter Serious maternal medical problems, such as cardiac, pulmonary, or neurologic disease Bleeding disorders Severe preeclampsia Previous history of anesthetic complications Obstetric complications likely to lead to operative delivery, eg, placenta previa or high-order multiple gestation |
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Absolute Contraindications to Regional Anesthesia
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Refractory maternal hypotension
Maternal coagulopathy Maternal use of once-daily dose of 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 |
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How treat post dural headache from spinal?
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Postdural puncture headache is possible with spinal analgesia but also can occur with combined spinal epidural and epidural analgesia (12, 15). Early conservative therapy for headache includes analgesics, supine positioning, and hydration. However, in 36% of cases, postdural puncture headache after spinal or combined spinal epidural is severe enough to require an autologous epidural blood patch
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How is genearl anesthesia managed?
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Because general anesthesia results in a loss of maternal consciousness, it must be accompanied by airway management by trained anesthesia personnel. Nitrous oxide may be supplemented with halogenated hydrocarbons, such as isoflurane, desflurane, and sevoflurane, at low concentrations. The use of intravenous agents, such as sodium pentothal, followed by rapid sequence induction is used to minimize the risk of aspiration.
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What are complications from pudendal block?
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Complications from pudendal block include intravascular injection of anesthetic agents, hematoma, and infection
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Absolute Contraindications to Regional Anesthesia are?
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Refractory maternal hypotension
Maternal coagulopathy Maternal use of once-daily dose of 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 |
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What transplacental passage of parenteral drugs cause neurobehaviour problems?
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There is significant transplacental passage of all parenteral drugs. A recent meta-analysis of several randomized trials revealed that parenteral analgesia is associated with a twofold to threefold increased risk of Apgar scores lower than 7 at 5 minutes and a fourfold increased need for neonatal naloxone (40), although the overall incidence of both was low. Although most neonatal depression is short-lived and can be treated as needed with naloxone, the long neonatal half-life of normeperidine (63 hours), an active metabolite of meperidine, has raised concerns regarding the prolonged duration of neonatal sedation following the administration of parenteral meperidine during labor (41, 42). Infants exposed to meperidine during labor demonstrate dose-dependent neurobehavioral depression that can be demonstrated on day 2 (43) and day 3 (44, 45) of life. Unlike other parenteral drugs, the neonatal effects of meperidine increase with a prolonged drug-to-delivery interval because of the accumulation of normeperidine (44, 45). Neonates exposed to transplacental nalbuphine are demonstrated to have a decreased response to sound and decreased tone and alertness for more than 24 hours after birth (35). Fentanyl also crosses the placenta but has not been associated with neonatal neurobehavioral depression
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Parenteral Agents for Labor Pain
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Meperidine-fetal effects
13–22.4 h 63 h for active metabolites Fentanyl Nalbuphine Butorphanol Morphine |
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Common Causes of Transient Urinary Incontinence are?
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Urinary tract infection or urethritis
Atrophic urethritis or vaginitis Drug side effects Pregnancy Increased urine production Metabolic (hyperglycemia, hypercalcemia) Excess fluid intake Volume overload Delirium Restricted mobility Stool impaction Psychologic |
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Common Causes of Transient Urinary Incontinence are?
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Detrusor overactivity (idiopathic)
Detrusor overactivity (neurogenic) Mixed types Fistula Vesical Ureteral Urethral Congenital Ectopic ureter Epispadias Nongenitourinary etiology Functional Neurologic Cognitive Psychologic Physical impairment Environmental Pharmacologic Metabolic |
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How does TVT work?
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The tension-free vaginal tape procedure is based on a theory that the pathophysiology of stress urinary incontinence is the impairment of the pubourethral ligaments (17). A narrow strip of polypropylene mesh is placed at the mid urethra to compensate for this inefficiency
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