Usmle Obs Gyn (Best Summarised)

Obstetrics Fetal assessment •

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Biophysical profile : - It's indicated in a) b) c)

: High risk pregnancies. Decreased fetal movements. Non-reactive NST.

- It consists of the following 5 parameters assessedby ultrasonography: 1- Nonstress test (reactive) 2- Fetal tone (flexion or extension of an extremity) 3- Fetal movement (at least 2 in 30 minutes) 4- Fetal breathing movements (at least 20 in 30 minuttes) 5- Amniotic fluid volume (single pocket greater than 2cm in vertical axis) 8-10 decreased amniotic fluid volume and a score of 8 6 without oligohydramnios 6 with oligohydramnios 4 or less 2 or less ~

•

- Considered normal. - Should be repeated once or twice weekly until term for high risk pregnancies. - Delivery is to be considered as fetal compromise is likely. - If the pt is greater than 37 weeks gestation 7 Delivery. - If the pt is less than 37 weeks gestation 7BPP should be repeated in 24 hours and delivery should be done if not improved. - If above 32 weeks gestation 7 required delivery. - If less 32 weeks gestation 7 daily monitoring - Delivery is indicated if the pt is greater than 26 weeks gestation - Severe fetal asphyxia 7 the baby should be delivered immediately.

In the presence of oligohydramnios (AFI < S) : delivery should be considered since it can result in umbilical cord compression and therefore fetal compromise.

FHR pattern : Types or decelerations

Definition & relationship to contr,ctlon

Varlab le deceleration

, Abrupt dec,eue In FHR below basellne • Onsel depth. and duratlon vary with con11ae1ion

• Cord compression • Low amniotic fluid • Fc"11 hypoxb

Late deceleration

, FHR gradually decreases with a delayed return to basdine • Nadir after peak ol contraclion

• Uteroplacen= 50% in a 20 min. period) variable deceleration 7 requires prompt intervention. The first step in the presence of any non-reassuring heart rate is : Administer oxygen & changing maternal position •

In presence if decreased fetal movement 7 suspect fetal compromise 7Non-stress test : reactive 7 most appropriate next step is : ReP-eat Non-stress test week • NST is usually performed in : 1) High risk pregnancies starting at 32 - 34 weeks. 2) Decreasefetal movement in any pregnancy. The most common cause of non-reactive is sleeping baby ( do Vibroacoustic stimulation) NOTa diseased baby Biophysical profile is done when : non-reactive+ no response to vibroacoustic stimulation.

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Screening during pregnancy •

O, lnhibin A O, Estriol 0-, MS-AFP 0-. B·HCG 0-, Estriol -0. , MS-AFP 0- . (all decreased)

Between 15-20 weeks 7 quadruple test to assess risk of Down's (trisomy21l : B-HCG

•

Edward (trisomvlSl· MS-AFP

1J

In presence of: 1- Inaccurate Gestation Age (first) 3- Neural Tube defects

1J or D-

Most appropriate next step in abnormal MS-AFP

2- Multiple gestation 4- Abdominal wall defects (gastroschisis,

is : ,Ultrasound

omphalocele)

7 to rule out the previous four items.

1- .RhJ~.~Ji.lJ&.P.r~_gn~n~Y..; Current guidelines recommend : Rh-blood W~ing AND testing for Rh antibodies at : • First prenatal visit • & repeat at 28 weeks 7 in unsensitized woman (Rh -ve) with her partner either: • Rh +ve (so the fetus is Rh +ve) or • Rh unknown To check the possible maternal alloimmunization during pregnancy 7 if negative 7 give anti-D at 28 weeks & at time of delivery. - ABO antibodies: lgM, don't cross the placenta - Rh antibodies: lg G, do cross the placenta.

•

ABO Alloimmunization incompatibility: Patient is missing a blood type,

Occur in 1st pregnancy (Primigravida)

in contrast to Rh in 2"d pregnancy

have antibodies to the missing antigens. Blood type A B

0

Antibodies against B A A&B

---AB Mother with blood group O AND Father with blood group AB 7 will develop baby with blood group either A or B (both differ from mother group) 7 so resulting in formation of lgG antibodies in the mother wich cross the placenta resulting in "Hemolytic

Disease of the Newborn (HDN)" which is : ild disease in most newborns ( than Rh factor does)

Affected infants are asymptomatic in at birth or with absent or mild anemia and develop neonatal jaundice, which is usually successfully treated with phototherapy.

2- ~~r.~~O.i.O&J9.L~Y.P..~!!.i.~ .. ; It is recommended that all pregnant women be screened for syphilis regardless of risk factors. Screening should be performed at the first prenatal visit and is typically via: Rapid plasma regain test (RPR) and venereal disease research laboratory test (VDRL).

-+

When the screening test is positive, the diagnosis can be confirmed with fluorescent treponemal antibody absorption (FT A-ABS) test.

Treatment with penicillin.

3-

I~P.~f~M!Q~!~.{I.~lJ~r.~~nJ.o_g_; High risk populations for tuberculosis are immigrants, women of low socioeconomic status, and HIV-positive women. Screening by : PPD (PositivePPDdoes not meon that the patient is infected) • PPD is positive when : It exceeds 10 mm in high-risk populations 5 mm in HIV patients. • All patients with positive PPD : -+ Should undergo a chest x-ray in order to exclude octive_tuberculosis"? before prescribing isoniazid prophylaxis. -+ Patients with a positive tuberculin skin test without any evidence of active tuberculosis are considered to have a latent tubercular infection (LTBI) 7These should be treated with isoniazid for a period of 9 months. When active tuberculosis arises in any individual (including a pregnant woman): In pregnant women stricken with tuberculosis that is not likely to be drug-resistant includes : isoniazld {INH), rifam~ln, and ethambutol for a _eeriod of 9 months.

7the standard treatment regimen

N.B. Streptomycin may be ototoxic for the fetus and should not be used in the pregnant woman.

CDC recommends The vaccine

that all pregnant

is recommended

Hb electrophoresis

C

Lead screening

without

contraindications

: receive influenza

vaccine

in flu season and can be given at any trimester.

Recommended family

Hepatitis

women

for those

a high risk of transmitting

hemoglobinopathy

based on

history (NOT ROUTINE!)

For evaluation

for those

at high risk risk (NO ROTUINE

).

For evaluation

for those

at high risk risk (NO ROTUINE

).

Tuts for every pregnant patient:

Tests for specific, at risk pregnant pll!lents:

• Cevical cytology (If It fits In Wllll tllelr routine scr«ning) • Rhesus type and antibody screen • Hematocrit, hemoglobin, and IJCV • Rt.befla irnmunfy • Variceila ITTlmunity • Urne cufture • SypMs 1esu,g • Hepaltls B ~nligen • Ctiomydio testing • HIV tes;;l

• Influenza vaccine dumg flu season • Ofter genetic screening for cystic fibrosis • Ofter Down syndrome testing

e TI1yroil runcoon ONLY II 5Yflll)tomabc, personal or femily history of dysfunction, or associated condition (i e , diabetes) • TB for at risll patienls • Toxoplasmosis serology for at risk patiens • HemoglOIMIH!leclloplloresis IOI

patJents with high-nsk ethnic bockgrOU'ld or IACV < 80

140/90 mmHg

+ Proteinuria > 0.3g/24 h After 20'h week of gestation

Mild Pre-eclampsia :

- At term or full lung maturity 7 delivery (most effective) - Away from term or No lung maturity : 1) Bed rest + observation 2) Methyldopa if BP> 160/110 3) Dexamthasone between 24th - 34'h weeks 7 delivery once mature lung. - The most appropriate initial medication to treat her hypertension proteinuria : MethyldoP.a.

160/110 mmHg + Proteinuria > 5g/24 h + Oliguria I HEELP I headache, blurred vision IP.edema I Mild or Severe preeclampsia + Grand mal convulsions

&

Hypertension> Severe Pre-eclampsia :

Eclampsia

- Seizure:

7 MgSo4 (ttt in eclampsia

in severe)

2) Terminate immediately once stabilization By C.S or induction labor. The cause of RUQ pain is "?liver cai:1sule(Glisson's) distention.

-- ~Rntr.~Jn.cJJ~~t~