OB/gyn student Study Guide Abbreviation and Definitions lmp: last menstrual period pmp



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OB/GYN Student Study Guide

Abbreviation and Definitions

LMP: last menstrual period

PMP: previous menstrual period

EDC: estimated date of confinement

GP: gravida, para: Gravida is how many pregnancies; Para is the number of

times the uterus is emptied

TPAL: (“Tennessee Power and Light”): Term (#) (the number

of term pregnancies – twins count as 1 pregnancy!) Preterm

(#) Abortions (elective or spontaneous #) Living # (all children

counted here)



G1P1002 = Twins
CKC: cold knife conization LEEP: loop electrocautery excision procedure

BTL: bilateral tubal ligation D&C: dilation and currettage POC: products of conception

Hystero: uterus TVH: transvaginal hysterectomy TAH: transabdominal hysterectomy

LAVH: laparoscopic assisted vaginal hysterectomy TLH: total laparoscopic hysterectomy

BSO: bilateral salpingoopherectomy
Oligo: few trachelo: cervix

Hyper: too much culpo: vagina

Hypo: not enough ectomy: removal of

Meno: menses ootomy: incision

Metr: uterus ostomy: making a new opening

Rrhea: flow centesis: needle into something

Rrhagia: excess flow polymenorrhea: cycle every 20 days
PROM: premature rupture of membranes PPROM: preterm premature rupture of membranes

SVD: spontaneous vaginal delivery LTCS: low transverse cesarean section

R LTCS: repeat LTCS FAVD: forceps assisted vaginal delivery VBAC: vaginal birth after c/s

VAVD: vacuum assisted vaginal delivery VMI: viable male infant VFI: viable female infant

SAB: spontaneous abortion (miscarriage) EAB: elective abortion

IUFD: Intrauterine fetal demise
ASCUS: atypical squamous cells of undetermined significance

LGSIL: low grade squamous intra epithelial lesion

HGSIL: high grade squamous intra epithelial lesion
1st Trimester: w0 – w12 gestational age

2nd Trimester: w12 – 28

3rd Trimester: w28 – 40

Previable: less than 20 weeks; if delivered considered Abortion, not SVD

Preterm: 24-37 w

Term: 37 – 42 w

Embryo: fertilization to 8 weeks

Fetus: 8 weeks to birth

Infant: delivery to 1 year

Post Dates: > 41-42 weeks


Pregnancy and Prenatal Care
Diagnosis: home UPT: highly sensitive at the time of missed cycle (positive at 8-9 d); bHCG rises to 100,000 by 10 weeks and levels off at10,000 at term; can get gestational sac as early as 5 weeks. At that point your bHCG should be 1500 to 2000.
Discriminatory Zone: This means that when BHCG is 1200-1500, evidence of a pregnancy should be seen on transvaginal ultrasound. When the BHCG is 6000, you can see evidence on a transabdominal ultrasound.

FHT: seen at ~6 weeks on US; Doppler FHT at 12 w
Gestational Age: days and weeks from LMP
Dating Age (not used except on tests!): weeks and days from fertilzation; GA 2 weeks greater than DA
Naegle’s Rule: For EDC: LMP – 3 months + 7 days + 1 year
Ultrasound: can be 1 week off in the first trimester, 2 weeks off in the second trimester, 3 weeks in the third trimester so… if your US differs from the EDC by LMP more than this, accept the US dating over the LMP dating. In the first half of the first trimester, use the Crown Rump Length (CRL) which is within 3 – 5 days of accuracy.
Doppler: can get FHT (fetal heart tones) at 12 weeks
Quickening: at 16 – 20 weeks (mom feels the baby move)
Signs and Sx of Pregnancy:

a. Chadwick’s Sign-blue hue of cervix

b. Goodell’s Sign – softening and cyanosis of cx at 4 weeks

c. Laddin’s Sign – softening of uterus after 6 weeks

d. Breast swelling and tenderness

e. Linea nigra

f. Palmar erythema

g. Telangiectasias

h. Nausea

i. Amenorrhea, obviously



j. Quickening

Normal Changes in Pregnancy:


  1. CV –

    1. CO inc by 30-50% @ max 20 – 40 weeks

    2. SVR dec secondary to inc. progesterone and therefore smooth muscle relaxation

    3. BP dec: systolic down 5 – 10/ diastolic down 10 – 15 until 24 weeks then slowly returns.

  2. Pulmonary:

    1. TV inc 30 – 40%

    2. Minute Vent inc 30 – 40%

    3. TLC dec 5% secondary to elevation of diaphragm

    4. PA O2 and pa O2 inc; dec pA CO2 and pa CO2

  3. GI:

    1. Nausea and vomiting in 70% - inc. estrogen, progesterone and HCG; resolves by 14 – 16 w

    2. Reflux – dec. GE sphincter tone

    3. Dec lower intestinal motility, inc water reabsorption and therefore constipation

  4. Renal

    1. Kidneys increase in size

    2. Ureters dilate – increased risk of pyelonephritis

    3. GFR inc 50% - BUN, Crt dec 25%

  5. Heme

    1. Plasma volume inc by 50%, RBC vol inc 20 – 30% - drop in Hct

    2. WBC still nl at 10 – 20 in labor

    3. Hypercoaguability

    4. Inc. fibrinogen, inc factors 7 – 10, dec 11 – 13

    5. Slight dec in plt, slight dec in PT/PTT

  6. Endocrine

    1. Inc estrogen from palcenta; dec from ovaries – low estrogen levels assn with fetal death and anencephaly

    2. Progesterone is produced by corpus luteum then the palcenta

    3. HCG – doubles roughly every 48 hours; peaks at 10 – 12 weeks; the alpha subunit looks like LH, FSH and TSH but the beta subunit differs

    4. Inc in thyroid binding globulins

  7. Musculoskeletal/Derm – Spider angiomata, melasma, linea nigra, palmar erythema

    1. Change in the center of gravity – low back pain.

  8. Nutrition – 2000 – 2500 cal/day

  • need to increase protein, calcium and iron- an iron supplement is needed in the second trimester. 30 mg of elemental iron is recommended

      1. folate is necessary early on to prevent nueral tube defect (spina bifida) – 400 mcg per day is recommended in women without seizure meds or previous infant with neural tube defect (4g are recommended then)

      2. 20 – 30 lb weight gain is OK, obese women do not have to gain weight.


Prenatal Care
First Trimester: CBC, Blood Type and Screen, RPR, Rubella, Hep B s Ag, HIV, UA/Cx, GC, Chl, PPD, Pap Smear (without cytobrush)

  • Appt q mo.

  • Doppler FHT @ 10 – 12 w

  • OK Drugs: Tylenol, Benadryl, Phenergan

  • Routine labs q visit: FHT, Fundus height, Urine dip (prt, bld, glucose, etc), weight, BP


Second Trimester: MSAFP/Triple Screen @ 15 – 18 wks, O’Sullivan @ 24 – 28 weeks

  • Quickening at 17 – 19 week

  • Glucose Tolerance Test Values: OSullivan: 50 g glucose  normal: under 140; if over then perform 100 g glucose tolerance test

  • Fasting 105

  • 1 hour 190

  • 2 hours 165

  • 3 hours 145

  • Rhogam @ 28 weeks


Third Trimester: RPR, CBC, Group B Strep 35-37 weeks (if not scheduled for repeat cesarean), cervical exam every week after 37 weeks or the onset of contractions

  • Labor precautions: “Go to L&D if you have contractions every 5 minutes, if you feel a sudden gush of fluid, if you don’t feel the baby move for 12 hours, or if you have bleeding like a period. It’s normal to have mucus or a pink discharge in the weeks preceding your labor.”


Routine Problems of Pregnancy:

Back Pain GERD Constipation

Hemorrhoids Varicose Veins Braxton Hicks

Pica (cravings) Dehydration Round ligament pain (inguinal pain, worse on

Edema Frequency walkingTX: Tylenol, heating pad,

Maternity belt)


MSAFP: produced by placenta: goes through amniotic fluid  mom

  • Inc MSAFP: neural tube defects,omphalocele,gastroschisis, mult gest, fetal death, incorrect dates

  • Dec MSAFP: Down’s, certain trisomies

  • TRIPLE SCREEN: MSAFP, Estriol, BHCG- risk for defects is calculated. If it comes back abnormal, make sure dating is accurate, then counsel patient and consider amniocentesis.

Triple Screen Tri 21 Tri 18

MSAFP dec dec

Estriol INC dec

BHCG INC dec


  • Amniocentesis can be done to get baby’s karyotype if abn US, aberrant MSAFP, Adv Maternal Age or Family history of abnormalities

  • Can do a Chorionic Villi Sampling @ 9 – 11 weeks if you need a karyotype sooner, have inc. risk of PPROM, previable delivery, fetal injury however.


PUBS: percutaneous umbilical blood sampling: gets fetal blood to test for degree of fetal anemia/hydops in Rh disease, etc.
Fetal Lung Maturity:

  • Lecithin/Sphingomyelin Ratio: over 2.0 indicates fetal lung maturity

  • “FLM”: Flouresence Polarization: >55mg/g is mature; good for use in diabetics

  • Phosphatidyl glycerol: comes back pos or neg: best for diabetics because is last test to turn positive; hyperglycemia delays lung maturity


Clinic Survival Guide Copy and put in your pocket!
Clinic note:

21 yo G2P1001 at 28 2/7 by 8 week ultrasound (always include dating criteria) complaining of inguinal pain on walking. Denies contractions, vaginal bleeding, rupture of membranes, and has fetal movement (the cardinal questions of obstetrics).

BP 110/68 Urine: trace protein (pregnant women usually have trace protein) neg glucose

Fundal Height(FH): (measured from the pubic symphysis to fundus- correlates within 1-2 cm unless obese) 29cm

Fetal Heart Tones (FHT): 140s (count them out on your watch in the beginning; normal 120s-160s)

Extremities: no calf tenderness

(any results of recent ultrasounds, lab work here)

A/P: 1. IUP at 28 2/7: size appropriate for dates

2. Round Ligament Pain: recommended maternity belt

3. RH Neg: Rhogam 300 mcg IM today

3. Continue PNV/ Fe, discussed preterm labor precautions

4. O Sullivan today

I.M. Student, L3

Complaints:



  • Discharge  do cultures, wet prep (look for trich); mucus normal at term

  • The baby doesn’t move at times  babies go through normal sleep cycles. As long as it moves every couple of hours, that’s fine. Kick counts- lie on side and count the amount of kicks in one hour after dinner- should be over 10.


Ectopic Pregnancy


  • Most common place – ampulla of the fallopian tubes; also located in ovary, abd wall, cervix, bowel

  • Risk factors: Infx of tube, PID, IUD use, previous tubal surgery, assited reproduction

  • Occur in 1/100 pregnancies

  • SS: episodic lower abd pain

    • Abnormal bleeding: due to inadequate progesterone support

    • HCG decreased: normally, HCG doubles every other day; in ectopics it doesn’t

    • Unilateral tenderness

    • +/- mass

    • Cullen’s sign (periumbical Hematoma)

    • U/S finding- complex adenexal mass, can see sac or fetus, even

  • TX: Methotrexate 50 mg/m2 if <4 cm, unruptured: follow serial HCGs 4 and 7 days later. You want the value to drop 15% between days 4 and 7. If it doesn’t, you give another dose of methotrexate. If the mass is > 4 cm then salpingostomy or salpingectomy (if patient is stable, can do this laparoscopically; if not needs emergent laparotomy)

  • Arias-Stella Rxn: assn with ectopic pregnancy; endometrial change that looks like clear cell carcinoma (but is not cancerous)


Spontaneous Abortions ( <20 weeks)


  • Occur in 15 – 25% of pregnancies

  • 60% assoc with abn chromosomes (#1 cause: Trisomy 16, #2: Monosomy X)

  • RF if recurrent: infx, maternal anatomic defects, Antiphospholipid Sd; endocrine problems (of mom), previous miscarriage

  • LABS to do: bHCG, CBC, type and screen, US; give Rhogam if Rh -

  • Definitions:

    • Threatened AB – intrauterine pregnancy with bleeding; closed cervix  needs initial obstetric visit

    • Missed AB – Fetal death without passage of products of conception; no FHT by 8 weeks

    • Inevitable AB – dilated cervix, proceeds to complete or incomplete

    • Incomplete AB – products not all out  do a D&C

    • Complete AB – Products all out; need to follow BHCG until 0 to make sure it was not a hydatidiform mole or choriocarcinoma

  • SS: bleeding, crampy abdominal pain (always ask if clot or whitish tissue was passed)

  • Abortion @ 6 – 8 week: 1. Trisomies 2. Turner’s Sd (45X)

  • Habitual Ab: 3 Ab’s in a row

    • Causes: balanced translocation of parents, autoimmune dz, abn uterus, etc.

    • WU: karyotype for balanced trans, antiphospholipid ab, hysterosalpinography for abn uterus (septate uterus most common)

  • Incompetent Cervix Sd: Ab’s between 13 – 22 weeks because cervix can’t hold POC in: see painless dilation and effacement in 2nd trimester; infx is common b/c of trauma/vaginal flora TX: McDonald’s Cerclage: a pursestring nonabsorpable suture around cervix: remove at term; also could manage expectantly; BEDREST – give steroids and Abx to dec infx and inc fetal lung maturity and tocolyze contractions; Both McDonald and Shirodkar are near the internal os – Shirodkar stitch just tunnels under the cervical epithelium.

  • Causes of 2nd Trimester Abs: infx, mat anat defects, cervical defects, systemic dz, fetotoxic agents, trauma (chromosomes occur in second trimester, but not as frequently as first trimester)


Chromosome Stuff


  • Trisomies: 13 Edwards, 18 Patou, 21 Down’s

  • Autosomal Dominant Dz: Neurofibromatosis, von Willebrand’s, Achondroplasia, Osteogenesis imperfecta

  • X Linked Dz: Muscular Dystrophy, G6PD Def, hemophilia

  • Recessive Dz: 12 OH Adrenal hyperplasia

  • McCune Albright: polyostotic fibrous dysplasia: degeneration of long bones, sexual precocity, café au lait spots (tx precocious puberty with medroxyprogesterone acetate)


Statistical Stuff


  • Maternal Mortality = mat death/100,000 live births

  • Fertility rate = # live births/1000 females 15 – 44

  • Birth rate = # live births / 1000 people


Antepartum Fetal Surveillance


  • NST = Non Stress Test: to be “reactive” need 2 accelerations, of 15 beats per minute for 15 seconds in 20 minute strip; if nonreactive, baby can be sleeping – give mom juice – do a BPP (think about sedatives, narcotics, CNS/CV abnormalities)

  • BPP = biophysical profile; on U/S 8 pts good/ 4 pts bad







Give 2 points

Give 0 points

NST

Reactive

< 2 accels

AFI (amniotic Fluid Index)

one 2 by 2 cm pocket

no pocket seen

Fetal Breathing Movements

Last over 30 seconds

< 30 seconds

Fetal Extremity Movements

3 or more episodes

Under 3 episodes

Fetal Tone

Extension to flexion; flex at rest

Extended at rest




  • Modified BPP = NST and AFI

  • Contraction stress test (CST): nipple stimulation or oxytocin – shows 3 uterine contactions in 10 minutes to be good; negative = no late decelerations

  • HOW TO READ THE STRIP:

    • Reassuring things – normal behavior, beat to beat variation, reactive strip (above)

    • Early decels – they begin and end with the contraction – a sign of head compression – OK

    • Variable decels – are more jagged and look like a V – a sign of cord compression – we may start amnioinfusion

    • Late decels – begin at peak of contraction and end after contaction is finished – a sign of uteroplacental insufficiency – are bad. (nonreassuring)

  • FSE = fetal scalp electrode- placed usually with IUPC when a more accurate recording of heart tones is needed; do not use in moms with HIV

  • IUPC = Intra Uterine Pressure Catheter – placed in uterus to monitor contractions; a good baseline is 10-15 mm Hg; Ctx in labor inc. 20 – 30 mmHg or even to 40 – 60; can amnioinfuse through the IUPC with normal saline- You cannot tell how strong a contraction is with the tocometer. You need an IUPC to count MonteVideoUnits.Over 200 MVUs is considered adequate.

  • Fetal Scalp pH; take blood from scalp for nonreassuring factors, fetal hypoxia (not really done anymore)

PH over 7.25 is reassuring 7.2 – 7.25 indeterminate <7.2 bad

Labor
DATING

  • Menstrual History: 40 weeks from LMP (Naegle’s rule: LMP + 7 days – 3 months)

  • Uterine Size:

  • Ultrasound: is most accurate at 8 – 12 weeks

  • Dating Criteria for delivery: determines whether lungs are considered mature for delivery

        1. FHT documented 30 weeks by Doppler.

        2. 36 weeks since UPT positive.

        3. US of CRL at 6-11 weeks makes gestational age >39 weeks.

        4. US of under 20 weeks supports gestational age >39 weeks.


STAGES OF LABOR

  • First: beginning of contractions to complete cervical dilation

    • Latent – to approx. 4 cm (or acceleration in dilation)

    • Active – to 10 cm complete; prolonged if slower than 1.2 cm/hr null/1.5 cm/h multip; if prolonged, do amniotomy, start pitocin, place IUPC to evaluate contraction strength

    • Failure to progress – no change despite 2 hours of adequate labor (MVU >200)

  • Second: complete dilation to the delivery of baby

    • Prolonged if 2 hours multip/ 3 hours nullip (with epidural) or 2 hours nullip/1 hour multip (no epid)

  • Third: delivery of baby to delivery of placenta

  • Fourth: one hour post delivery


3 P’S OF LABOR

  1. Power: nl contractions felt best at fundus; last 45-50 seconds; 3 in 10 minutes

  2. Passenger:

    1. Presentation – what is at the cervix (head (vertex), breech)

    2. Position – OA, OP, LOT, ROT

    3. Attitude – relationship of baby to itself

    4. Lie – long axis of baby to long axis of mom

    5. Engagement – biparietal diameter has entered the pelvic inlet

    6. Station – presenting part’s relationship to ischial spine (-3, -2, -1, 0, 1, 2, 3)

  3. Pelvimetry:

    1. Inlet: Diagonal Conjugate – symphysis to sacral promontory = 11.5 cm

Obstetrical Conjugate – shortest diameter = 10 cm

    1. Midplane: spines felt as prominent or dull

    2. Outelt: Bituberous Diameter = 8.5 cm

Subpubic Angle less than 40 degrees

FORCEPS

  • Outlet forceps: requirements –

      • visible scalp

      • Skull on pelvic floor

      • Occiput Anterior or Posterior

      • Fetal head on perineum : can see without separating labia

      • Adequate anesthesia; bladder drained

      • Maximum 45 degrees of rotation

  • Low forceps:

      • station 2 but skull not on pelvic floor




  • Midforceps: station higher than 2 with engaged head (not done)


VACCUUM EXTRACTION: can cause cephalophematoma and lacerations

  • Same requirements for outlet forceps


INDUCTION:

  • Indications: PreEclampsia at term, PROM, Chorioamnionitis, fetal jeopardy/demise, >42w, IUGR

  • Bishop Scoring System: if induction is favorable: >8 vaginal delivery without induction will happen same as if with induction: < 4 usually fail induction: < 5 – 50% fail induction




Score

Cm

Effacement

Station

Consistency

Position of cx

0

0

0-30%

-3

Firm

Post

1

1-2

30-50%

-2

Med

Mid

2

3-4

60-70%

-1,0

Soft

Ant

3

4-5

>80%

+1, +2









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