Ob/Gyn #

OCPs 101 #

NO changes for 3 months Takes body a little bit to get used to everything => can start chasing your tail if making too many changes too quick

• Start at 20mcg estrogen
  • If PMS-like symptoms => ↓ estrogen
  • If spotting => ↑ estrogen
  • Usually start w/ levonorgestrel
    • If acne/bloating => switch progesterone from levo to norethindrone
• If you decrease estrogen, generally decrease progesterone too
• If pt “too moody” => try nuvaring
• Depoprovera gotchas
  • Long return to fertility
  • Weight gain
• If pt with pre-existing acne => Yaz (drospirenone + estrogen)
• Mirena
  • Not fun being placed, but tolerable
  • More progesterone
    • More chance amenorrhea
    • More chance of acne
    • More moodiness
• Kyleena
  • Less progesterone
    • Less moodiness
    • Less acne
    • Less chance of no period
• Cheap OCPs
  • Lutera (20) ← default to this, sliightly lower estrogen
  • Sprintec (35)

Ovarian Cysts #

• Simple cyst is physiologic
• Repeat US in 6 weeks to confirm it’s simple
• Treatment
  • OCPs
  • If on OCPs
    • Journal symptoms
    • APAP/ibuprofen/naproxen before the day to control

Trimesters #

• 1st: 0-14wks
• 2nd: 14-26wks
• 3rd: 27-40wks

OB Visits #

AFI #

• Sum of deepest pocket of amniotic fluid in each of four quadrants (Radiopedia)
• Must keep probe perpendicular to floor (i.e. straight up and down)
• Normal 5-25cm
• <5cm OR single deepest pocket less than 2cm = oligo

Thyroid #

Titrate to TSH of 2.5 or below for pregnant or trying to get pregnant patients.

Anemia in pregnancy #

• Definition: <5%-ile
  • 1st tri 11g/dL or 33%
  • 2nd tri 10.5 or 32%
  • 3rd tri 11 or 33%
• Plasma volume ↑ 40-50%, erythrocytes only ↑ 15-25%
• Prevalance ≈2%
  • Black women: ≈3.5%
  • White women: ≈1.8%
  • Per trimester
    1. 6.9%
    2. 14.3%
    3. 29.5%
• Increases risk of:
  • Low birth weight
  • preterm delivery
  • perinatal mortality
  • PPD?

Mechanism #

• Production ↓
  • Lack of materials
    • iron
    • B12
    • Folate
  • Broken machienery
    • bone marrow issues/supression
      • hypothyroidism
    • renal dysfunction (EPO)
• Destruction ↑
  • Inheritied
    • sickles, thalassemias, hereditary spherocytosis
  • Acquired
    • Autoimmune
    • TTP
    • HUS
    • Malaria
• Broken cells
  • Thalessemias
  • Hemolytic anemias
• Loss

Screening #

• CBC at intake and at 24-28 weeks

Iron supplimentaiton #

• need 27mg Fe per day
• Start all women on low dose (CDC+, ACOG+, USPSTF +/-)
• Consider IV iron if severe or if can’t tolerate oral iron
• transfuse
  • Hgb <6g/dL => affects baby
• Consider cell salvage
  • Jehovah’s witness

Labor #

Real labor contractions happen every five mins, lasting one minute

Labor = cervical change + contractions

Anticipated amount of time for active labor:

• G0 w/ epidural 4hrs
• G0 w/o epidural 3hrs
• G1+ w/ epidural 2hrs
• G1+ w/o epidural 1hr

Progression #

Preventing First Cesarian

Pain Control #

Four options:

• Au Natural
• Nitrous oxide
  • Relaxes you, but doesn’t really treat pain
• IV fentanyl
  • Doesn’t take away all the pain, but works and goes fast
  • Great for CRB placement
  • Can’t give close to delivery as makes sleepy babies
• Epidural
  • Can’t walk
  • Slows second stage of labor by approx. 30 mins (not a huge deal)

Morphine sleep #

• morphine
• phenergan
• recheck in 8 hours, can go home after that

Strips #

VEAL CHOP

Examples and practice

Inductions #

• Cytotec plus foley
• Pitosin then AROM

Failure #

• No change in 4hrs with adequate contractions
• No change in 6hrs regardless of contractions

Cervical Change #

• Cytotec
  • PO or vaginal q4hrs
• Cervadil
  • vaginal q12hrs
• Foley
  • 50cc; dilates to 3-4cm
• Cook cath
  • 50cc; dilates to 5cm
• Walking (natural)
  • gravity
• Nipple stim (natural)
  • Stim one nipple for a 30 sec contraction
  • Switch nipples
• Sex (natural)
  • oxytocin from orgasm
• Strip membranes
  • thought to release endogenous prostaglandins

Check Bishop score

Contractions #

• AROM
  • Best in multips who want to go “natural”
• Pitocin (oxytocin)
  • Start at 2
  • Increase by 2 every 30 mins

Post Partum Hemorrhage (PPH) #

>1000mL within 24hrs of delivery (either vaginal or c/s)

Treatment #

1. Pitocin
   • Can give two bags
2. Misoprostol (Cytotec) 800-1000mcg rectally
   • Can give 200mg PO
   • Slow onset
   • Can cause N/V, mild fever
3. Methergine 0.2mg IM q2-4hrs
   • Fast acting
   • Contraindicated in patients with hypertension (relative)
   • 6 dose max
     • Some use the 2-4-6 rule
       • 0.2 every 4 hrs for 6 doses
4. Hemabate 0.25mg q15-90 minutes
   • Contraindicated in patients with asthma
   • 8 dose max
   • Causes wicked diarrhea
   • Give with lomotil or nurses will hate you
5. TXA 1-2g per 500mL-1L bag
   • Can repeat 1x
   • Only helps with clotting, not a uterotonic

Hypertensive Diseases of Pregnancy Spectrum #

a. Either, 4 hours apart
b. PIH labs: CBC (plts), CMP (Scr and LFTs), P/C, UA, LDH
c. One of: plts <100k, LDH >600, Scr > 1.1 or 2x baseline, LFTs 2x upper range of normal

Pre-eclampsia (PreE) #

Treatment #

Magnesium (Mg)

1. Bolus 4-6g
   • Can give 5g IM x2 (both cheeks)
2. Infusion 2g/hr

• Reflexes disappear as becomes therapeutic (pts are hyperreflexic when in PreE)
• UOP needs to be 0.5mL/kg/hr
  • Mg renally excreted
• Reversal agent: Ca gluconate
  • Only really used if cardiac toxicity
• Toxicity:
  • >15 respiratory paralysis
  • >25 cardiac abnormalities

Miscarriage #

Criteria:

• No cardiac activity after US with cardiac activity

Management #

• Expectant
• Misoprostol
  • Only up to estimated 9w0d GA
    • Higher risk of bleed and not completing past this GA
  • 800mcg vaginally at bedtime
    • Can take roughly 6 hours to start working
  • 800mg ibuprofen at same time to help with cramping/pain
  • Repeat x1 in 24 hours
• D&C
  • Indicated if past 9w0d

Quick Ob Triage #

HPI #

• Vaginal bleeding
• Loss of fluid
• Contractions
• Complications of pregnancy
• Fetal movement
• Vitals
• FHTs/strip interpretation
• Rh +/- status
• GBS status

Labor Check #

• <34 Weeks
  • Put baby on monitor
    • If not contracting → discharge
  • Check cervix
    • if <5 and contracting → hold, recheck in few hours
    • if >5 and contracting → admit
• >34 Weeks
  • SSE collect FFN, KOH/wet mount (FFN no good if has had sex in last 24hrs)
  • Transvaginal US for cervical length
    • If >2.5cm → stable
    • If 1.5-2.5cm → send FFN
    • If <1.5 → corticosteroids/tocolytics
  • Cervical exam
    • If <2cm → stable
    • If >2cm → corticosteroids/tocolytics

ROM #

• >34 Weeks
  • Speculum exam (pooling, nitrazine, ferning/Amnisure)
    • If positive, admit and check cervix
    • If negative, check AFI
• <34 Weeks
  • Speculum exam
    • Pooling, nitrazine, ferning/Amnisure
    • KOH/wet mount
    • Urine dip
  • TVUS → cervical length
  • If +ROM
    • Admit
    • Give latency abx
    • GBS culture
    • Mg if <32 weeks
    • +/- MFM consult
  • If neg ROM
    • Check AFI

Gestational HTN/Preeclampsia (Pre-E) #

Pre-E = HTN + proteinuria after 20 weeks

• Monitor BPs
• Check sx
  • Persistent HA (does not respond to acetominophen)
  • Visual changes (scotoma; floaters)
  • Epigastric pain
  • DTRs
• Labs
  • CBC (look for plts <100k)
  • CMP (LFTs 2x normal, creatine > 1.1, Uric acid increased)
  • UA (protein)
  • Urine protein/creatine ratio (>0.3mg)

2nd/3rd Trimester Bleeding #

• Speculum exam
• CBC
• Coags
• Blood type (thinking Rhogam)
• Transabdominal US
  • Placentation
  • Signs of abruption

Trauma #

• Monitor for 4hrs
• Labs
  • CBC
  • Coags
  • Type and screen (Rhogam)
  • Transabdominal US
    • Placentation
    • Signs of abruption
• Consider Rhogam if abruption suspected
• Normal ACLS/Intubation
  • Place pillow under R hip to help displace gravid uterus from decending aorta

Decreased Fetal Movement #

• NST
• AFI

Breastfeeding #

• Milk generally comes in between days 3-5
• Ok to have tender nipples for the first week, never ok after that

General info/fun facts:

• “Baby friendly” is a global designation steming from the WHO and UNICEF
• #1 cause of infant death worldwide is diarrheal illness from unclear water (i.e. used to mix formula)
• “Babies are like a drunk at a bar–they don’t care if it’s a bottle or a nipple…” -Carolyn (Lactation)

What to look for:

• Latch score <7 needs work
• Amount of time doesn’t matter
• Try to finish one side before switching → more fat at end

Breast infection with Serratia creates flourescent pink milk

To abruptly stop milk production:

• Cabbage leave
• Break veins
• Put in bra
• Replace when wilted

Engorgement #

• Actually an imflammatory process (not excess milk/too much volume)
• generally lasts 24-36hrs
• Ice, NSAIDs/anti-inflammatories

WIC #

• Doesn’t “favor”/push formula
• Will provide breast pumps and parts
• Will do both breast and formula but needs indication

Drug safety databases:

• LactMed (More libral)
• InfantRisk (more conservative but favored by lactation)
• Hale’s Medications and Mother’s Milk (book)

Pearls #

• Left hydronephrosis normal in pregnancy
• Normal physiologic changes in pregnancy: ↑ V_t, ↑ HR, ↓ BP
• Uterine inversion can cause a vaso-vagal response: ↓ HR, ↓ BP
• Limit caffiene to <200mg caffiene/day while pregnant (per ACOG, although so evidence that up to 400mg ok)
• Do a good vulvar/shallow vaginal exam on labor admits if have hx of HSV
• Breakthrough bleeding
  • progesterone 200mg qday until stopped (Agestin is more expensive)
  • OCP taper (for younger): 2 pills x 3 days then finish pack