OB OSCE

REVIEWER FOR OB-GYN OSCE

OB SCORE G P (T-P-A-L) G: Number of pregnancy P: deliveries that reached the 20 weeks T: pregnancies delivered term (37 weeks) P: pregnancies delivered 20 weeks A: pregnancies that ended before or at 20 weeks L: number of living children OBSTETRIC HISTORY 1. General Data 2. Chief Complaint 3. Past Medical History 4. Family Medical History 5. Personal-Social History 6. Menstrual History 7. Sexual History 8. Obstetric History 9. Contraceptive History 10. Gynecologic History 11. History of Present Illness/Pregnancy COMPUTATION OF EDC/EXPECTED DATE OF DELIVERY  Average duration o f pregnancy o 40 weeks or 280 days o 10 lunar months or 9 calendar months Naegele’s Rule – Rule – based  based on a normal 28-day cycle From the LNMP: o - deduct 3 months, add 7 days to the date, and add 1 year - If January to March: +9 in months, +7 in days - If April to December: -3 in months, + 7 in days, + 1 in year

REPRODUCTIVE TRACT CHANGES IN PREGNANCY Hegar’s Sign: softening Sign: softening of the lower uterine segment/isthmus Goodell’s Sign: softening Sign:  softening of the cervix due to increased vascularity Chadwick’s Sign: Bluish Sign: Bluish discoloration of the vaginal and cervical mucosa Others: - Dextrorotation of the uterus - Braxton Hicks’ contraction - Corpus luteum in the ovaries (6-7 weeks)  

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TEN DANGER SIGNS OF PREGNANCY The following should be asked if present during prenatal check-ups: 1.  Any vaginal bleeding ble eding 2. Swelling of the face and/or fingers 3. Severe or continuous headache 4. Dimness or blurring of vision 5.  Abdominal pain 6. Persistent vomiting 7. Chills or fever 8. Dysuria 9. Escape of fluid from the vagina 10. Marked change in frequency or intensity of fetal movements

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CLINICAL DATING OF PREGNANCY Ultrasound dating is most accurate in the first 12 weeks of pregnancy o 4-6 weeks: use of GS diameter o 6-12 weeks: use of CRL (most accurate dating of early pregnancy) nd o 2  trimester: Biparietal diameter (most accurate); femoral length; abdominal circumference rd o 3  trimester:  femoral length (FL) Quickening  – 18-20 wks o Primigravida – 18-20  – 16-18 wks o Multigravida – 16-18 Size of the uterus (fundic height in cm) ~ AOG in wks between 20  – 32  – 32 wks Fetal heart tone by Doppler at 10-12 wks Fetal heart tone by stethoscope by 20-22 wks 

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SCHEDULE OF PRENATAL CARE Intervals of 4 weeks until 28 weeks (every month for first 7 months) Then every 2 weeks until 36 weeks (every 2 weeks until 9 months) Weekly thereafter (until the patient comes into labor) For complicated pregnancies: return visits at 1- to 2-week intervals    

WHO FOCUSED ANTENATAL CARE For low-resource setting in countries like South Africa First visit – visit – 8-12  8-12 weeks Second visit – visit – 24-26  24-26 weeks Third visit – visit – 32  32 weeks Fourth visit – visit – 36-38  36-38 weeks without any anticipated complications (80%) median of five visits (versus 8 in the routine)       

PRENATAL DIAGNOSTIC TESTS REQUESTED in the OPD Test CBC-PC

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12 weeks: just weeks:  just above the symphysis pubis 16 weeks: halfway weeks:  halfway between symphysis pubis and umbilicus 20 weeks: level weeks:  level of umbilicus 28 weeks: 6 weeks:  6 cm above the umbilicus 36 weeks: 2 weeks:  2 cm below the the xyphoid process 40 weeks: 4 weeks:  4 cm below the xyphoid process (due to lightening)

Rationale To determine for presence of anemia < 11 g/dL :  1st and 3rd trimester < 10.5 g/dL : 2nd trimester To determine risk for Rh incompatibility 

Blood typing VDRL/ RPR

Screening (non-treponemal) tests for syphilis If positive, request for FTA-ABS, TPHA (confirmatory) DOC for syphilis in all stages: PENICILLIN G If allergic to Penicillin  desensitize JARISCH-HERXHEIMER JARISCH-HERXHEIMER REACTION: Acute febrile reaction that usually occurs 24 hrs after treatment To determine presence of Hepatitis B infection HBsAg If reactive, request for Total anti-HBc to determine whether acute or chronic; HBeAg to determine infectivity HIV 1 & 2 HIV screening; code used in the chart is VCT Urinalysis Ideally, urine culture is requested To determine if the patient has UTI (any form of infection places the patient at risk for preterm labor)  Also, UA may reveal glu cosuria  DM; or proteinuria preeclampsia  preeclampsia Ultrasound Transvaginal: if less than 12 weeks Transabdominal: more than 12 weeks Fetal Biometry Biophysical Scoring Congenital Anomaly Scan  

ESTIMATING FETAL WEIGHT / JOHNSON’S RULE EFW = (FH – n) x 0.155 FH: Fundic Height n = 11 if engaged; n = 12 if not engaged

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VDRL: Venereal Disease Research Laboratory; RPR: Rapid Plasma Reagin; Fluorescent Treponemal Antibody ABSorption (FTA-ABS); Treponema Pallidum Haemagglutination Assay (TPHA)

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FETAL BIOMETRY CONGENITAL ANOMALY SCAN Done at 18-20 weeks’ AOG weeks’ AOG Biparietal Diameter (BPD) Head circumference (HC) Indications: Maternal Age o Abdominal circumference (AC) History of Previous Child with congenital anomaly o - Least reliable in terms of aging because it is made out of Family history of congenital anomaly o soft tissue - Most important parameter in determining fetal weight Femur Length (FL) - Most reproducible BIOPHYSICAL SCORING 

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CERVICAL EXAM

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Performed after determination of fetal lie, the second maneuver (Umbilical Grip) is accomplished as the palms are placed on either side of the maternal abdomen, and gentle but deep pressure is exerted. - FETAL BACK: hard, resistant convexity EXTREMITIES: numerous small, irregular, mobile - FETAL EXTREMITIES: parts

This is almost always asked during endorsement conferences. conferences . Do not forget to ask the resident for the IE findings to ge t the Bishop score.

LEOPOLD’S MANEUVER The first three maneuvers are done with the examiner facing the patient’s head. The final maneuver is done with the examiner facing the  patient’s feet.

1.

The first maneuver (Fundal Grip) permits identification of which fetal pole— pole—that is, cephalic or podalic— podalic—occupies the uterine fundus. - BREECH:  large, nodular mass - HEAD: round, movable, ballotable mass - TRANSVERSE:  empty

What fetal pole occupies the fundus?

On which side is the fetal back? 3.

The third maneuver (Pawlik’s Grip) is performed by grasping with the thumb and fingers of one hand the lower portion of the maternal abdomen just above the symphysis pubis. - NOT ENGAGED: easily displaced, round, ballotable mass - ENGAGED:  Fixed, knob-like part

What fetal part lies above the pelvic inlet? 2

4.

To perform the fourth maneuver (Pelvic Grip), the examiner faces the mother’s feet and, with the tips of the first three fingers of each hand, exerts deep pressure in the direction of the axis of the pelvic inlet. In many instances, when the head has descended into the pelvis, the anterior shoulder may be differentiated readily by the third maneuver. - HEAD FLEXED: cephalic prominence on the same side as the fetal small parts - HEAD EXTENDED:  cephalic prominence is on the same side as the fetal back

BASELINE FETAL HEART RATE The baseline must be for a minimum of 2 minutes in any 10-min segment. - Normal FHR baseline: 110-160 bpm - Tachycardia: > 160 bpm - Bradycardia: < 110 bpm On which side is the cephalic prominence?

CLINICAL PELVIMETRY

BASELINE VARIABILITY Fluctuations in the baseline FHR which are irregular in amplitude and frequency. Visually quantified as the amplitude of peak-to- trough in beats per minute - Absent: amplitude range undetectable - Minimal: amplitude range detectable but 5 bpm or fewer - Moderate (Normal): amplitude range 6-25 bpm - Marked: amplitude range >25 bpm

CARDIOTOCOGRAM (CTG)  Accurate FHR assessment assessmen t may help in determi ning the status of the fetus and indicate management steps for a particular condition. In order to accurately assess a FHR pattern, a description of the pattern should include qualitative and quantitative information in the following five areas: 1. Baseline rate 2. Baseline FHR variability 3. Presence of Accelerations 4. Periodic or episodic decelerations 5. Changes or trends of FHR patterns over time 3

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Due to head compression

LATE DECELERATIONS - In association with a uterine contraction, a visually apparent, gradual (onset to nadir 30 sec or more) decrease in FHR with return to baseline - Onset, nadir, and recovery of the deceleration occur after the beginning, peak, and end of the contraction, respectively - Indicates uteroplacental insufficiency 

ACCELERATION  A visually apparen t increase (onset to pe ak in less than 30 sec) in the FHR from the most recently calculated baseline - The duration of an acceleration is defined as the time from the initial change in FHR from the baseline to the return of the FHR to the baseline - At 32 weeks of gestation and beyond , an acceleration has an acme of 15 beats per min or more above baseline, with a duration of 15 sec or more but less than 2 min - Before 32 weeks of gestation , an acceleration has an acme of 10 beats per min or more above baseline, with a duration of 10 sec or more but less than 2 min - Prolonged acceleration lasts acceleration lasts 2 min or more, but less than 10 min - If an acceleration lasts 10 min or longer, it is a baseline change VARIABLE DECELERATIONS - An abrupt (onset to nadir less than 30 sec), visually apparent decrease in the FHR below the baseline - The decrease in FHR is 15 beats per min or more, with a duration of 15 sec or more but less than 2 min - due to by cord compression

DECELERATION - Transient episode of slowing of the FHR below the baseline level of more than 15 bpm and lasting 15 sec or more. - If rate is below 110 bpm and duration is >10min: BRADYCARDIA EARLY DECELERATIONS - In association with a uterine contraction, a visually apparent, gradual (onset to nadir 30 sec or more) decrease in FHR with return to baseline

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Nadir of the deceleration occurs at the same time as the peak of the contraction

PROLONGED DECELERATION - Visually apparent decrease in FHR below the baseline, 15 bpm or more, lasting 2 min or more but less than 15 min in duration. SINUSOIDAL PATTERN - Visually apparent smooth, sine wave-like undulating pattern in FHR baseline with a cycle frequency of 3-5 bpm which persists for 20 min or more 4

UTERINE CONTRACTIONS

2. 3. 4.

Sudden gush of blood Uterus rises in the abdomen Lengthening of the umbilical cord

Mechanisms of Placental Extrusion SCHULTZ’S MECHANISM DUNCAN’S MECHANISM Initial separation is CENTRAL Initial separation in the Bleeding is hidden PERIPHERY Fetal side appears first in the Gush of blood will precede the introitus followed by the gush of appearance of the maternal blood side of the placenta ―SHINY‖  membranes ―DIRTY‖  cotyledons

INTERPRETATION:

FOUR STAGES OF LABOR First Second Third Fourth

Onset of uterine contraction until full cervical dilatation Full cervical dilatation until delivery of the baby Delivery of the baby until delivery of the placenta One hour after delivery of the placenta

FIRST STAGE OF LABOR  A. Latent Phase - < 3 cm - For Primigravid: 8 hours - For Multigravid: 4-5 hours B. Active Phase - > 3 cm - Three Phases: 1. Acceleration Phase: predictive of outcome of labor; >3-4 cm 2. Maximum Slope: good measurement of overall efficiency of the uterus; >5-7 cm 3. Deceleration Phase: reflective of fetopelvic relationship; >8-10 cm

Maneuvers in the delivery of the Placenta 1. BRANDT – ANDREWS MANEUVER - abdominal hand secures the uterine fundus to prevent uterine inversion while the other hand exerts sustained downward traction on umbilical cord 2. MODIFIED CREDE’S MANEUVER - cord is fixed with lower hand while the uterine fundus is secured and sustained upward traction is applied using abdominal hand Active Management of the 3 rd Stage of Labor 1. Uterotonics 2. Delayed cord clamping 3. Controlled cord traction 4. Uterine massage UNANG YAKAP / ESSENTIAL NEWBORN CARE 1. Immediate drying 2. Uninterrupted skin-to-skin contact 3. Proper cord clamping and cutting 4. Non-separation of the newborn from the mother for early breastfeeding initiation and rooming-in

CARDINAL MOVEMENTS OF LABOR E-D-F-IR-E-ER-E

Engagement  Descent  Flexion  Internal Rotation  Extension  External rotation  Expulsion

SECOND STAGE OF LABOR - 50 minutes for nulliparas - 20 minutes for primiparas THIRD STAGE OF LABOR Signs of Placental Separation 1. Uterus from discoid becomes globular and firmer – firmer – earliest  earliest sign (Calkin’s sign) 5

VAGINAL SPONTANEOUS DELIVERY 1.  Aseptic Technique 2. Drape the patient 3. Place in dorsal lithotomy position to increase the diameter of the pelvic outlet 4. Inject anesthesia on the site of episiotomy 5. Do episiotomy 6. Ritgen Maneuver with perineal support 7. Slide hand along the neck to check for nuchal cord 8. Wipe baby’s face 9. Pull head downwards 10. Pull upward once the anterior shoulder is seen 11. Deliver the baby 12. One hand supports the head, the other slides along the back to grasp the feet 13. Put plastic clamp or tie tightly around cord at 2 cm and the forceps 5 cm from baby’s abdomen. (Clamp and cut cord after cord pulsations stop) 14. Cut between ties with a sterile instrument 15. Dry and wrap the baby 16. Give the baby to the Pedia for ENC

PLACENTAL INSPECTION 1. Inspect for blood vessels: two arteries, one vein (AVA) 2. Cord length (Williams: Most umbilical cords are 40 to 70 cm long) - Check for true knots, false knots, kinks, clots 3. Type of insertion - Central, paracentral, peripheral, velamentous 4.  Arborization of vessel s over the fetal surface - Vessels should taper toward the edge - If exceeds up to outer 1/3, suspect accessory lobe 5. Check the fetal membranes -  Amnion: fetal side wi th vessels - Chorion: maternal side; avascular - If yellowish, indicates chorioamnionitis 6. Check for completeness of cotyledons (Normal: 10-38) 7. Check for infarction (placenta previa), hematoma (abruption placenta), hemorrhages, flattening

Arrest in Cervical Dilatation

Arrest in Descent

Prolonged Deceleration Phase

EXAMPLES OF FRIEDMAN’S CURVE Normal Labor Pattern

CLASSIFICATION OF PERINEAL LACERATIONS First-degree involve the fourchette, perineal skin, and vaginal lacerations mucous membrane but not the underlying fascia and muscle First degree PLUS the fascia and muscles of the Seconddegree perineal body but not the anal sphincter lacerations Third-degree extend farther to involve the external anal lacerations sphincter  extend completely through the rectal mucosa to Fourthexpose its lumen and thus involves disruption of degree both the external and internal anal sphincters lacerations

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EPISIOTOMY Episiotomy: incision of the pudendum— pudendum—the external genital organs Perineotomy: incision of the perineum 

Storage Duration of Fresh Human Milk for Use with Healthy Full Term Infants: (Reference: CDC)

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MEDIOLATERAL EPISIOTOMY was the most powerful predictor of wound disruption Episiotomy is completed when the head is visible during a contraction to a diameter of approximately 4 cm , that is, crowning. When used in conjunction with forceps delivery, most perform an episiotomy after application of the blades .

TYPES OF SUTURES TYPE

USES

MONOFILAMENT vs MULTIFILAMENT

REMARKS

NON-ABSORBABLE SUTURES:  not broken down by the body (permanent suture) 1. Silk Skin (High tension Multifilament / Black and areas) Braided ―magaspang‖ - Back - Mobile skin 2. Nylon Skin (Low tension Monofilament ―Shiny‖ areas) “fishing line”  - Face - Scalp 3. Cotton Multifilament 4. Prolene Vascular Monofilament (Polypropylene) anastomoses, abdominal fascial closure ABSORBABLE SUTURES:  completely broken down by the body (dissolving suture) 1. Vicryl Peritoneum, etc Multifilament / Can be white or (Polyglactin) Braided purple; hydrolyzed 2. Chromic Catgut Peritoneum, Color brown; mucosa, etc more resistant to break and less irritating 3. Plain catgut Subcutaneous tissue Peritoneum 4. PDS Monofilament (Polydiaxanone) 5. Monocryl Monofilament

BENEFITS OF BREASTFEEDING B-est for babies R-educe allergies E-conomical A-ntibodies S-atisfies nutritional need T-emperature constant and correct

F-resh milk never spoils E-motional bonding E-asy once established D-igested easily after 2-3 hrs I-nhibits ovulation N-o mixing required G-I problems reduced

E.O. 51: The Milk Code of the Philippines

Store milk toward the back of the freezer, where temperature is most constant. Milk stored for longer durations in the ranges listed is safe, but some of the lipids in the milk undergo degradation resulting in lower quality.

FAMILY PLANNING METHODS NATURAL: 1. CALENDAR/RHYTHM CALENDAR/RHYTHM METHOD - Monitor menstrual cycle of 6-12 months - Subtract 18 from the shortest cycle and 11 from the longest cycle   fertile period 2. STANDARD DAYS METHOD - Effective of menstrual cycles are 26 to 32 days long - Fertile Days = days 8-19 - Safe days = days 1-7 and days 20 up to the next cycle 3. CERVICAL MUCUS/BILLING’S METHOD - Fertile: slippery and elastic - Safe/Not fertile: scant and dry 4. BASAL BODY TEMPERATURE -  At least 3 hours continuou s sleep - Oral temperature for 5 minutes taken before rising - 0.5°C increase for at least 3 consecutive days - No intercourse from onset of menstruation until the third consecutive day of elevated basal temperature. 5. SYMPTO-THERMAL METHOD - Calendar method and changes in cervical mucus to estimate onset of fertile period and changes in cervical mucus and BBT estimate its end 6. LACTATION-AMENORRHE LACTATION-AMENORRHEA A METHOD - Mother has fully breastfed the infant - Mother has remain amenorrheic - Effective up to 6 months only, therefore need for additional form of contraception. ARTIFICIAL: Hormonal: 1. Oral Contraceptive Pills 2. Injectables 3. Steroid Implants 4. Combined Patch 5. Combined Rings

Non-Hormonal – Barrier: 1. Intrauterine Device 2. Condom 3. Diaphragm 4. Cervical Cap 5. Sponge

PERMANENT: 1. Bilateral Tubal Ligation 2. Vasectomy

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DILATATION AND CURETTAGE Types of Curettage: 1. Completion Curettage - Therapeutic - For obstetric cases (e.g. abortion, retained placenta) - Steps: Sound  Endometrial  Resound - Instruments (you must be able to identify): a. Vaginal retractor b. Tenaculum forceps c. Ovum forceps d. Sharp curette e. Uterine forceps f. Hysterometer

Steps in Doing Fractional Curettage 1. Identify patient, explain the procedure, place in dorsal lithotomy position under sedation 2.  Aseptic technique 3. Drape 4. Bladder catheterization 5. IE for corpus size determination and orientation (cervix anterior or posterior?) 6.  Apply posterior vaginal wall retractor  7. Grasp the anterior lip of cervix using tenaculum forceps 8. Proceed with endocervical curettage using the smallest curette until enough specimen is acquired. Put aside 9. Initial uterine sounding using hysterometer ; corresponds to uterine depth 10. Proceed with endometrial curetting. Curette until gritty (endometrium) and bubbly (arterial blood vessel) 11. Final uterine sounding 12. Remove instruments 13. Final asepsis 14. Patient tolerated the procedure well OR Findings: Cervix open, smooth, with uterine depth of 9 cm, evacuated scanty mucoid soft tissue from the endocervix and approximately approximately 1 teaspoonful of soft, spongy, non-foul smelling reddishtan tissue from endometrium endometrium

FORCEPS DELIVERY Basic Design of Obstetric Forceps

(Top: vaginal retractor, tenaculum forceps, ovum forceps; Bottom: hysterometer, sharp curette)

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Fractional Curettage - Both diagnostic and therapeutic - For gynecological cases (e.g. AUB, myoma) - Obtain endocervical and endometrial curettings - Steps: Endocervical  Sound  Endometrial

Steps in Doing Completion Curettage 1. Identify patient, explain the procedure, place in dorsal lithotomy position under sedation 2.  Aseptic technique 3. Drape 4. Bladder catheterization 5. IE for corpus size determination and orientation (cervix anterior or posterior?) 6.  Apply posterior vaginal wall retractor  7.  Apply tenaculum forceps on anterior lip of cervix 8. Initial uterine sounding using hysterometer ; corresponds to uterine depth 9. Use ovum forceps to remove placental tissues and retained products of conception 10. Curette until gritty (endometrium) and bubbly (arterial blood vessel) 11. Final uterine sounding 12. Remove instruments 13. Final asepsis 14. Patient tolerated the procedure well OR Findings: Cervix open, smooth, with uterine depth of 9cm, evacuated approximately approximately 1 teaspoonful teaspoonful of soft, spongy, non-foul smelling reddish-tan tissue from endometrium

Each blade has two curves Cephalic curve: conforms to the shape of the fetal head Pelvic curve: conforms to the axis of the birth canal  

FUNCTIONS OF FORCEPS Traction Rotation INDICATIONS OF FORCEPS DELIVERY MATERNAL FETAL Heart Disease Prolapse of umbilical cord Pulmonary Injury/Compromise Premature separation of the placenta Intrapartum Infection Non-reassuring FHR Certain neurologic condition pattern Exhaustion Prolonged second-stage of labor 

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PREREQUISITES PREREQUISITES FOR FORCEPS APPLICATION 1. The cervix must be completely dilated. 2. The membranes must be ruptured. 3. The head must be engaged. 4. The fetus in vertex presentation, or present a face with the chin anterior. 5. The position of the head must be precisely known. 8

6.

There should be no suspected cephalopelvic disproportion.

TYPES OF FORCEPS:

4. For the application of the right blade, two or more fingers of the left hand are introduced into the right posterior portion of the vagina to serve as a guide for the right blade. 5. This blade is held in the right hand and introduced into the vagina as described for the left blade. 6.  After positioning, the bran ches are articulated articula ted and locked. locked .

Traction: 1. If necessary, rotation to occiput anterior is performed before traction is applied. CLASSIFICATION OF FORCEPS DELIVERY ACCORDING TO STATION AND ROTATION OUTLET FORCEPS Criteria: 1. Scalp is visible at the introitus without separating the labia. 2. Fetal skull has reached the pelvic floor. 3. Sagittal suture is anteroposterior diameter or right or left occiput anterior or posterior position. 4. Fetal head is at or on perineum. 5. Rotation does not exceed 45 degrees. LOW FORCEPS Criteria: 1. Leading point of fetal skull is at station greater than or equal to station +2 and not yet on the pelvic floor, and: 2. Rotation is 45 degrees or less or 3. Rotation is greater than 45 degrees MIDFORCEPS Criteria: Station Criteria: Station is between 0 and +2

2. 3. 4. 5. 6.

Gentle, intermittent, horizontal traction is exerted until the perineum begins to bulge.  As the vulva is distende d by the occiput, an ep isiotomy may be performed in indicated.  Additional horizo ntal traction is app lied, and the hand les are gradually elevated, eventually pointing almost directly upward. During the birth of the head, traction should be intermittent, and only with each uterine contraction. Forceps may be removed, and delivery completed by Ritgen maneuver (perineal support.

HIGH FORCEPS (not ( not included in t he classification)

OUTLET FORCEPS DELIVERY Forceps Application: 1. Two or more fingers of the right hand are introduced inside the left posterior portion of the vulva and into the vagina beside the fetal head. 2. The handle of the left branch is then grasped between the thumb and two fingers of the left hand. 3. The tip of the blade is then gently passed into the vagina between the fetal head and the palmar surface of the fingers of the right hand.

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DYSTOCIA

ABORTION

HYDATIDIFORM MOLE 

The classic histological findings of molar pregnancy include: - villous stromal edema - trophoblast proliferation

Signs and Symptoms of Molar Pregnancy: Bleeding  Amenorrhea Disparity in the size of the uterus and the age of gestation Exaggerated signs of pregnancy Passage of tapioca-like materials per vagina Diagnostics: Pelvic Ultrasound reveals ―snowstorm ―snowstorm appearance‖ appearance‖ Beta-hCG is higher compared to a normal singleton pregnancy Differentials: Polyhydramnios Placenta previa  Abruptio placenta Multiple pregnancy Treatment: Suction curettage for termination of pregnancy Replacement of blood loss Prophylactic chemotherapy Beta-hCG serial monitoring for 18 months     

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ECTOPIC PREGNANCY Implantation of the blastocyst outside the endometrial lining of the uterus Most common site: ampulla of the fallopian tube Triad: abdominal pain, vaginal bleeding, amenorrhea Diagnostics: - hCG - Serum progesterone 140mmHg or Diastolic BP >90mmHg for the first time in pregnancy. - No proteinuria - BP returns to normal/resolves before 12 weeks postpartum PREECLAMPSIA

PLACENTA PREVIA VS ABRUPTIO PLACENTA PLACENTA PREVIA Painless vaginal bleeding Normal uterine tone Patient rarely in labor Fetal parts usually palpable Unengaged (-) Toxemia Placenta implanted at the lower uterine segment

ABRUPTIO PLACENTA Painful vaginal bleeding Hypertonic tender uterus In labor Fetal parts difficult to palpate Engaged (+) Toxemia Normally implanted placenta

GESTATIONAL DIABETES IF AVERAGE RISK, screening done at 24-28 weeks’ AOG IF HIGH RISK, screening is done as early as feasible Severe obesity Strong family history of type 2 DM Previous history of GDM, glucosuria, impaired glucose metabolism   

ECLAMPSIA - Onset of convulsions in a woman with preeclampsia that cannot be attributed to other causes CHRONIC HYPERTENSION WITH SUPERIMPOSED PREECLAMPSIA - New onset proteinuria >300mg/24 hours in hypertensive women but no proteinuria before 20 weeks’ gestation o r blood pressure or o r platelet -  A sudden increase i n proteinuria or count < 100,000/ul in women with hypertension and proteinuria before 20 weeks’ gestation CHRONIC HYPERTENSION HYPERTENSION - BP of 140/90mmHg before pregnancy or diagnosed before 20 weeks’ gestation not attributable to gestational trophoblastic disease; or - Hypertension first diagnosed after 20 weeks’ gestation and persistent after 12 weeks postpartum HELLP SYNDROME (Tennessee Classification) Hemolysis as evidenced by an abnormal peripheral smear in addition to either serum LDH >600 IU/L, or total bilirubin >1.2mg/dl Elevated Liver enzymes (AST/ALT) >70 IU/L Low Platelets < 100,000 cells/mm3 

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The test should be performed in the morning after an overnight fast of at least 8 hr but not more than 14 hr and after at least 3 days of unrestricted diet (≥ 150 g/d) and physical activity. The subject should remain seated and should not smoke during the test.

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DOC for urgent control of severe hypertension: Hydralazine - Max dose: 20 mg IV DOC for maintenance: Methyldopa DOC for prevention of eclampsia: Magnesium Sulfate - Loading dose: 4 g SIVP, 5 g on each buttocks - Maintenance dose: 5 g on alternating buttocks q6 x 4 doses - Therapeutic level of MgSO4:  4-7 mEq/L  10 meq/L: Patellar reflexes disappears  12 meq/L: Respiratory paralysis  >12 meq/L: Respiratory arrest

- Antidote: Calcium gluconate Hypertensive Work-up: CBC-PC: sudden decrease in hemoglobin and hematocrit may indicate hemolysis; to determine presence of thrombocytopenia (for the diagnosis of HELLP Syndrome) Liver enzymes (AST, ALT): for the diagnosis of HELLP Syndrome LDH: if elevated, may indicate hemolysis Bilirubin: if elevated, may indicate hemolysis BUN and Creatinine: if elevated, may indicate severe preeclampsia Urinalysis: to determine presence of proteinuria Serum Na, K, Cl, Mg, Ca, uric acid 

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FIGO CLASSIFICATION SYSTEM (PALM-COEIN) FOR CAUSES OF ABNORMAL UTERINE BLEEDING IN NONGRAVID WOMEN OF REPRODUCTIVE AGE

CERVICAL CANCER - Fifth leading site of cancer for both sexes combined - Second most common among women - Risk Factors: HPV infection, Early coitarche, Multiple sexual partners, Smoking, OCPs, Low socioeconomic status - MC Histopathologic Type: Squamous - Symptoms: Abnormal vaginal bleeding (MC), vaginal discharge, pain, urinary incontinence - Signs: erosion, mass, bulky endocervical canal, anemia, weight loss, cachexia - Most important prognostic factor: Stage - Diagnosis: Biopsy - Treatment of choice for all stages: Radiotherapy - Other treatment modalities: Surgery, Chemotherapy - Causes of death: Uremia, hemorrhage, sepsis

UTERINE FIBROIDS / LEIOMYOMA - Most common neoplasm in women Types: 1. Submucous 2. Subseous 3. Intramural (most common) 4. Intraligamentary Risk Factors: 1. Increasing age 2. Early menarche 3. Low parity 4. Tamoxifen use 5. Obesity Signs and Symptoms: 1. Usually asymptomatic 2.  Abnormal bleedi ng, usually inter menstrual spotting Differentials: 1. Pregnancy 2.  Adenomyosis 3. Ovarian neoplasm Diagnostics: Ultrasound Management: 1. Observation for small, asymptomatic myoma 2. Myomectomy or hysterectomy depending on the age, parity, and future reproductive plans 3. Medical: GnRH agonists, Danazol, aromatase inhibitors, medroxyprogesterone acetate OVARIAN NEW GROWTH Functional Cysts: - Corpus luteum cyst - Theca lutein cyst - Follicular cyst EPITHELIAL CELLS TUMORS

GERM CELL TUMORS

• Serous tumor • Teratoma - Mature • Mucinous tumor  - Immature • Endometrioid tumor • Dysgerminoma • Clear cell tumor  • Endodermal sinus • Brenner tumor  tumor • Choriocarcinoma • Embryonal carcinoma

SEX-CORD STROMAL TUMORS • Fibroma • Granulosa-Theca cell tumor • Sertoli-Leydig cell tumor

Evaluation of Pelvic and Abdominal Masses Found on Physical Examination

ENDOMETRIOSIS vs ADENOMYOSIS ENDOMETRIOSIS

- Located outside the uterus;

ADENOMYOSIS

- Located at least 2.5 mm from the basalis

most common: ovary

- Caused by retrograde (Sampson’s theory: menses (Sampson’s most popular) - Responds to cyclic changes

- From aberrant glands of basalis

Ultrasound Findings in Patients with a Pelvic Mass

- Does not respond to cyclic

- Prevalent in nulliparous

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(mid-30s) - Causes infertility and dysmenorrhea

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- Dx: Laparoscopy, UTZ, MRI - Medical Tx: Danazol, GnRH

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agonist - Surgical Tx: TAHBSO / TAH with ovaries preserved

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changes Common in multiparous women Causes dysmenorrhea and menorrhagia Diffusely enlarged uterus Dx: UTZ, MRI Medical Tx: GnRH, Progestogen, cyclic OCPs, NSAIDs Surgical: Hysterectomy

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CAUSES OF FEMALE PELVIC PAIN 1. Torsion 2. Pelvic inflammatory disease 3. Ovarian new growth 4.  Appendicitis 5. Endometriosis 6.  Adenomyosis 7.  Acute Appendicitis

PAP SMEAR used to obtain cells from the cervix for cervical cytology screening When to start cervical cancer screening?  Age 18 or once sexu ally active NOT later than 21 3 years after onset of vaginal intercourse No previous screening, positive cervical cancer history, DES exposure, positive HIV    

Patient Preparation: Refrain from using tampons, birth-control foams, jellies or other vaginal creams for 2-3 days before the test. No need to douche for 2-3 days before the test. No sexual intercourse for 2 days before the test. The best time is at least 5 days after menstrual period stops. 

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Procedure: 1. Prepare materials: 3 cotton-tipped applicator, 1 glass slide, fixative (95% ethyl alcohol), gloves, KY jelly 2. Introduce self, explain procedure, ask for OB score, LNMP, history of D&C 3. Place in dorsal lithotomy position, drape the patient, focus the droplight 4. Wear gloves 5. Wet the vaginal speculum with PNSS 6. Push the posterior vaginal wall with an index finger 7. Insert speculum obliquely about 45 degrees, then downward 8. Open the speculum and look for cervix, then lock 9. Get cotton pledgets and take specimen from the endocervix, swab in a ―Z‖ manner over the 1/3 of the glass slide. Throw the use cotton pledget. 10.  Another cotton pledg et for the ectocervix, swab again a gain over the middle third of the glass slide. Throw the use cotton pledget. 11.  Another cotton pledg et for lateral vagin al wall, swab agai n over the last third of the glass slide. Throw the use cotton pledget. 12. Place the slide with specimen in a fixative 13. Do IE after speculum exam. 14. Wash hands. 15. Complete the request, then send to the laboratory. Interpretation: Superficial Intermediate Parabasal

Estrogen Progesterone  Androgen

Reproductive Secretory Menopause

HPV VACCINE Gardasil ® (Merck) Cervarix ® (GlaxoSmithKline) Quadrivalent Bivalent  Against HPV types 6, 11, 16  Against HPV types 16 and 18 and 18 Intramuscular Intramuscular 0-, 2-, 6-month schedule 0-,1-,6-month schedule HPV Types 16 and 18: high risk; can cause cervical cancer HPV Types 6 and 11: low risk; can cause genital warts

TRICHOMONAS, MONILIASIS, GRAM STAINING 1. Prepare materials: cotton-tipped applicator, 3 glass slides, fixative (NSS), gloves, KY jelly 2. Introduce self, explain the procedure, ask for OB score, LNMP, history of D&C 3. Place in dorsal lithotomy position, drape the patient, focus the droplight 4. Wear gloves 5. Wet the vaginal speculum with PNSS 6. Push the posterior vaginal wall with an index finger 7. Insert speculum obliquely about 45 degrees, then downward 8. Open the speculum and look for cervix, then lock 9. Get cotton pledget and collect three specimens from the discharge of the cervix 10. Prepare 3 slides: - Trichomonas: NSS - Moniliasis: KOH - Gram stain: Crystal violet, iodine, alcohol, safranin Diagnostic Cues for Sexually Transmitted Infections Cue STI Agent Clue Cells Polymicrobial Bacterial Vaginosis usually Gardnerella Fishy odor after vaginalis Whiff Test Granuloma Klebsiella Donovan Bodies Inguinale granulomatis Chancroid Hemophilus ducreyi School of Fish Neiserria Intracellular Gonorrhea gonorrheae diplococci

MENOPAUSE

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the time when there has been no menstrual period for 12 consecutive months During this period, LH and FSH levels gradually rise because of diminished estrogen production. The fall in estradiol levels leads to hot flashes, mood changes, insomnia, depression, osteoporosis, and vaginal atrophy Average age: 48 years old (Philippines)

Types: Natural or Induced

Management: 1. Hormonal Replacement Therapy: Estrogen + Progestogen 2. Selective Estrogen Receptor Modulators (SERMS): Raloxifene, Droloxifene, Tamoxifen 3. Tibolone: has SERM-like property 4. Others: Calcitonin, Intermittent PTH 5. Bisphosphonates: Alendronate, Zolendronate 6. Calcium, Vitamin D 7. Exercise  Note: There are also QUESTIONS on  ETHICAL CONSIDERATIONS CONSIDERATIONS in the practice of OB-GYN  Examples:  Example s: Autonomy, Autonomy, Confidentiality, Confidentiality, Principle Principle of Double Double Effect

Read at your own risk.

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