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REVIEWER FOR OB-GYN OSCE

OB SCORE REPRODUCTIVE TRACT CHANGES IN PREGNANCY


G P (T-P-A-L) Hegars Sign: softening of the lower uterine segment/isthmus
G: Number of pregnancy Goodells Sign: softening of the cervix due to increased
P: deliveries that reached the 20 weeks vascularity
T: pregnancies delivered term (37 weeks) Chadwicks Sign: Bluish discoloration of the vaginal and
P: pregnancies delivered <37 weeks but >20 weeks cervical mucosa
A: pregnancies that ended before or at 20 weeks Others:
L: number of living children - Dextrorotation of the uterus
- Braxton Hicks contraction
OBSTETRIC HISTORY - Corpus luteum in the ovaries (6-7 weeks)
1. General Data
2. Chief Complaint TEN DANGER SIGNS OF PREGNANCY
3. Past Medical History The following should be asked if present during prenatal check-ups:
4. Family Medical History 1. Any vaginal bleeding
5. Personal-Social History 2. Swelling of the face and/or fingers
6. Menstrual History 3. Severe or continuous headache
7. Sexual History 4. Dimness or blurring of vision
8. Obstetric History 5. Abdominal pain
9. Contraceptive History 6. Persistent vomiting
10. Gynecologic History 7. Chills or fever
11. History of Present Illness/Pregnancy 8. Dysuria
9. Escape of fluid from the vagina
COMPUTATION OF EDC/EXPECTED DATE OF DELIVERY
10. Marked change in frequency or intensity of fetal movements
Average duration of pregnancy
o 40 weeks or 280 days SCHEDULE OF PRENATAL CARE
o 10 lunar months or 9 calendar months
Intervals of 4 weeks until 28 weeks (every month for first 7 months)
Naegeles Rule based on a normal 28-day cycle
Then every 2 weeks until 36 weeks (every 2 weeks until 9 months)
o From the LNMP:
Weekly thereafter (until the patient comes into labor)
- deduct 3 months, add 7 days to the date, and add 1 year
For complicated pregnancies: return visits at 1- to 2-week intervals
- If January to March: +9 in months, +7 in days
- If April to December: -3 in months, + 7 in days, + 1 in year
WHO FOCUSED ANTENATAL CARE
CLINICAL DATING OF PREGNANCY For low-resource setting in countries like South Africa
Ultrasound dating is most accurate in the first 12 weeks of First visit 8-12 weeks
pregnancy Second visit 24-26 weeks
o 4-6 weeks: use of GS diameter Third visit 32 weeks
o 6-12 weeks: use of CRL (most accurate dating of early Fourth visit 36-38 weeks
pregnancy) without any anticipated complications (80%)
o 2nd trimester: Biparietal diameter (most accurate); femoral median of five visits (versus 8 in the routine)
length; abdominal circumference
o 3rd trimester: femoral length (FL) PRENATAL DIAGNOSTIC TESTS REQUESTED in the OPD
Quickening Test Rationale
o Primigravida 18-20 wks CBC-PC To determine for presence of anemia
o Multigravida 16-18 wks < 11 g/dL : 1st and 3rd trimester
Size of the uterus (fundic height in cm) ~ AOG in wks between 20 < 10.5 g/dL : 2nd trimester
32 wks Blood To determine risk for Rh incompatibility
Fetal heart tone by Doppler at 10-12 wks typing
Fetal heart tone by stethoscope by 20-22 wks VDRL/ Screening (non-treponemal) tests for syphilis
RPR If positive, request for FTA-ABS, TPHA (confirmatory)
DOC for syphilis in all stages: PENICILLIN G
If allergic to Penicillin desensitize
JARISCH-HERXHEIMER REACTION: Acute febrile
reaction that usually occurs 24 hrs after treatment
HBsAg To determine presence of Hepatitis B infection
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)
12 weeks: just above the symphysis pubis Also, UA may reveal glucosuria DM; or proteinuria
16 weeks: halfway between symphysis pubis and umbilicus preeclampsia
20 weeks: level of umbilicus
28 weeks: 6 cm above the umbilicus Ultrasound Transvaginal: if less than 12 weeks
36 weeks: 2 cm below the the xyphoid process Transabdominal: more than 12 weeks
40 weeks: 4 cm below the xyphoid process (due to lightening) Fetal Biometry
Biophysical Scoring
ESTIMATING FETAL WEIGHT / JOHNSONS RULE Congenital Anomaly Scan
EFW = (FH n) x 0.155 VDRL: Venereal Disease Research Laboratory; RPR: Rapid Plasma Reagin;
FH: Fundic Height Fluorescent Treponemal Antibody ABSorption (FTA-ABS); Treponema Pallidum
n = 11 if engaged; n = 12 if not engaged Haemagglutination Assay (TPHA)

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

CERVICAL EXAM 2. 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
- FETAL EXTREMITIES: numerous small, irregular, mobile
parts

This is almost always asked during endorsement conferences. Do not forget to


ask the resident for the IE findings to get the Bishop score.

LEOPOLDS MANEUVER
The first three maneuvers are done with the examiner facing the patients
head. The final maneuver is done with the examiner facing the patients feet.

1. The first maneuver (Fundal Grip) permits identification of which On which side is the fetal back?
fetal polethat is, cephalic or podalicoccupies the uterine
fundus. 3. The third maneuver (Pawliks Grip) is performed by grasping
- BREECH: large, nodular mass with the thumb and fingers of one hand the lower portion of the
- HEAD: round, movable, ballotable mass maternal abdomen just above the symphysis pubis.
- TRANSVERSE: empty - NOT ENGAGED: easily displaced, round, ballotable mass
- ENGAGED: Fixed, knob-like part

What fetal pole occupies the fundus? What fetal part lies above the pelvic inlet?

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4. To perform the fourth maneuver (Pelvic Grip), the examiner
faces the mothers 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 may help in determining 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

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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 apparent increase (onset to peak 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 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 PROLONGED DECELERATION
EARLY DECELERATIONS
- Visually apparent decrease in FHR below the baseline, 15 bpm
or more, lasting 2 min or more but less than 15 min in duration.
- In association with a uterine contraction, a visually apparent,
gradual (onset to nadir 30 sec or more) decrease in FHR with SINUSOIDAL PATTERN
return to baseline
- Visually apparent smooth, sine wave-like undulating pattern in
- Nadir of the deceleration occurs at the same time as the peak of FHR baseline with a cycle frequency of 3-5 bpm which persists
the contraction for 20 min or more

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2. Sudden gush of blood
3. Uterus rises in the abdomen
UTERINE CONTRACTIONS 4. Lengthening of the umbilical cord

Mechanisms of Placental Extrusion


SCHULTZS MECHANISM DUNCANS 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

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
INTERPRETATION: sustained downward traction on umbilical cord
2. MODIFIED CREDES 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 3rd 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
FOUR STAGES OF LABOR 4. Non-separation of the newborn from the mother for early
First Onset of uterine contraction until full cervical dilatation breastfeeding initiation and rooming-in
Second Full cervical dilatation until delivery of the baby
Third Delivery of the baby until delivery of the placenta CARDINAL MOVEMENTS OF LABOR
Fourth One hour after delivery of the placenta E-D-F-IR-E-ER-E
Engagement Descent Flexion Internal Rotation
FIRST STAGE OF LABOR Extension External rotation Expulsion
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

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 earliest
sign (Calkins sign)

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Arrest in Cervical Dilatation
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 babys 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 babys abdomen. (Clamp and cut cord after
cord pulsations stop) Arrest in Descent
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 vessels 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 with vessels Prolonged Deceleration Phase
- 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

EXAMPLES OF FRIEDMANS 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
Second- First degree PLUS the fascia and muscles of the
degree perineal body but not the anal sphincter
lacerations
Third-degree extend farther to involve the external anal
lacerations sphincter
Fourth- extend completely through the rectal mucosa to
degree expose its lumen and thus involves disruption of
lacerations both the external and internal anal sphincters

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EPISIOTOMY Storage Duration of Fresh Human Milk for Use with Healthy Full
Episiotomy: incision of the pudendumthe external genital Term Infants: (Reference: CDC)
organs
Perineotomy: incision of the perineum

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. Store milk toward the back of the freezer, where temperature is most
constant. Milk stored for longer durations in the ranges listed is safe,
TYPES OF SUTURES but some of the lipids in the milk undergo degradation resulting in
MONOFILAMENT vs lower quality.
TYPE USES REMARKS
MULTIFILAMENT
NON-ABSORBABLE SUTURES: not broken down by the body (permanent
suture) FAMILY PLANNING METHODS
1. Silk Skin (High tension Multifilament / Black and NATURAL:
areas) Braided magaspang 1. CALENDAR/RHYTHM METHOD
- Back - Monitor menstrual cycle of 6-12 months
- Mobile skin - Subtract 18 from the shortest cycle and 11 from the longest
2. Nylon Skin (Low tension Monofilament Shiny cycle fertile period
areas) fishing line 2. STANDARD DAYS METHOD
- Face - Effective of menstrual cycles are 26 to 32 days long
- Scalp - Fertile Days = days 8-19
3. Cotton Multifilament
4. Prolene Vascular Monofilament
- Safe days = days 1-7 and days 20 up to the next cycle
(Polypropylene) anastomoses, 3. CERVICAL MUCUS/BILLINGS METHOD
abdominal fascial - Fertile: slippery and elastic
closure - Safe/Not fertile: scant and dry
ABSORBABLE SUTURES: completely broken down by the body (dissolving 4. BASAL BODY TEMPERATURE
suture) - At least 3 hours continuous sleep
1. Vicryl Peritoneum, etc Multifilament / Can be white or
- Oral temperature for 5 minutes taken before rising
(Polyglactin) Braided purple;
hydrolyzed - 0.5C increase for at least 3 consecutive days
2. Chromic Catgut Peritoneum, Color brown; - No intercourse from onset of menstruation until the third
mucosa, etc more resistant to consecutive day of elevated basal temperature.
break and less 5. SYMPTO-THERMAL METHOD
irritating - Calendar method and changes in cervical mucus to
3. Plain catgut Subcutaneous
estimate onset of fertile period and changes in cervical
tissue
Peritoneum mucus and BBT estimate its end
4. PDS Monofilament 6. LACTATION-AMENORRHEA METHOD
(Polydiaxanone) - Mother has fully breastfed the infant
5. Monocryl Monofilament - Mother has remain amenorrheic
- Effective up to 6 months only, therefore need for additional
BENEFITS OF BREASTFEEDING form of contraception.
B-est for babies F-resh milk never spoils
R-educe allergies E-motional bonding ARTIFICIAL:
E-conomical E-asy once established Hormonal: Non-Hormonal Barrier:
A-ntibodies D-igested easily after 2-3 hrs 1. Oral Contraceptive Pills 1. Intrauterine Device
S-atisfies nutritional need I-nhibits ovulation 2. Injectables 2. Condom
T-emperature constant and correct N-o mixing required 3. Steroid Implants 3. Diaphragm
G-I problems reduced 4. Combined Patch 4. Cervical Cap
5. Combined Rings 5. Sponge
E.O. 51: The Milk Code of the Philippines
PERMANENT:
1. Bilateral Tubal Ligation
2. Vasectomy

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DILATATION AND CURETTAGE Steps in Doing Fractional Curettage
Types of Curettage: 1. Identify patient, explain the procedure, place in dorsal
1. Completion Curettage lithotomy position under sedation
- Therapeutic 2. Aseptic technique
- For obstetric cases (e.g. abortion, retained placenta) 3. Drape
- Steps: Sound Endometrial Resound 4. Bladder catheterization
- Instruments (you must be able to identify): 5. IE for corpus size determination and orientation (cervix
a. Vaginal retractor anterior or posterior?)
b. Tenaculum forceps 6. Apply posterior vaginal wall retractor
c. Ovum forceps 7. Grasp the anterior lip of cervix using tenaculum forceps
d. Sharp curette 8. Proceed with endocervical curettage using the smallest
e. Uterine forceps curette until enough specimen is acquired. Put aside
f. Hysterometer 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 1 teaspoonful of soft, spongy, non-foul smelling reddish-
tan tissue from endometrium

FORCEPS DELIVERY
Basic Design of Obstetric Forceps

(Top: vaginal retractor, tenaculum forceps, ovum forceps;


Bottom: hysterometer, sharp curette)

2. 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 Each blade has two curves
5. IE for corpus size determination and orientation (cervix Cephalic curve: conforms to the shape of the fetal head
anterior or posterior?) Pelvic curve: conforms to the axis of the birth canal
6. Apply posterior vaginal wall retractor
7. Apply tenaculum forceps on anterior lip of cervix FUNCTIONS OF FORCEPS
8. Initial uterine sounding using hysterometer; corresponds Traction
to uterine depth Rotation
9. Use ovum forceps to remove placental tissues and
retained products of conception INDICATIONS OF FORCEPS DELIVERY
10. Curette until gritty (endometrium) and bubbly (arterial MATERNAL FETAL
blood vessel) Heart Disease Prolapse of umbilical cord
11. Final uterine sounding Pulmonary Injury/Compromise Premature separation of
12. Remove instruments Intrapartum Infection the placenta
13. Final asepsis Certain neurologic condition Non-reassuring FHR
14. Patient tolerated the procedure well Exhaustion pattern
Prolonged second-stage of
OR Findings: Cervix open, smooth, with uterine depth of 9cm, evacuated labor
approximately 1 teaspoonful of soft, spongy, non-foul smelling reddish-tan
tissue from endometrium
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.

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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 branches are articulated and 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. 2. Gentle, intermittent, horizontal traction is exerted until the
5. Rotation does not exceed 45 degrees. perineum begins to bulge.
3. As the vulva is distended by the occiput, an episiotomy may be
LOW FORCEPS performed in indicated.
Criteria:
1. Leading point of fetal skull is at station greater than or equal to station
4. Additional horizontal traction is applied, and the handles are
+2 and not yet on the pelvic floor, and: gradually elevated, eventually pointing almost directly upward.
2. Rotation is 45 degrees or less or 5. During the birth of the head, traction should be intermittent, and
3. Rotation is greater than 45 degrees only with each uterine contraction.
6. Forceps may be removed, and delivery completed by Ritgen
MIDFORCEPS maneuver (perineal support.
Criteria: Station is between 0 and +2

HIGH FORCEPS (not included in the 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 Signs and Symptoms of Molar Pregnancy:


The classic histological findings of molar pregnancy include: Bleeding
- villous stromal edema Amenorrhea
- trophoblast proliferation 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 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 OUT PATIENT GLUCOSE TARGETS FOR GDM
Implantation of the blastocyst outside the endometrial lining of the Pre-prandial glucose concentrations < 95 mg/dL
uterus 1hr post meal < 140mg/dL
Most common site: ampulla of the fallopian tube
Triad: abdominal pain, vaginal bleeding, amenorrhea 2 hrs post meal < 120mg/dL
Diagnostics:
- hCG POSTPARTUM MANAGEMENT
- Serum progesterone <5 ng/mL 75 grams OGTT at 6 to 12 weeks postpartum
- Culdocentesis reveals non-clotting blood which indicates Recommendations for postpartum follow up are based on 50%
hemoperitoneum from ruptured ectopic pregnancy likelihood of women with GDM developing overt diabetes within
- Transvaginal UTZ 20 years
- Laparoscopy (GOLD STANDARD)
Management: HYPERTENSIVE DISORDERS
- Medical: Methotrexate (folic acid antagonist)
- Surgical: GESTATIONAL HYPERTENSION
Laparoscopy is preferred unless hemodynamically - New onset uncomplicated hypertension during pregnancy when
unstable no evidence of the preeclampsia syndrome was apparent.
Salpingostomy: typically used to remove a small - Systolic BP >140mmHg or Diastolic BP >90mmHg for the first
unruptured pregnancy that is usually < 2 cm in length time in pregnancy.
and located in the distal third of the fallopian tube - No proteinuria
(CONSERVATIVE) - BP returns to normal/resolves before 12 weeks postpartum
Salpingectomy: may be used for both ruptured and
unruptured ectopic pregnancies (RADICAL) PREECLAMPSIA

PLACENTA PREVIA VS ABRUPTIO PLACENTA


PLACENTA PREVIA ABRUPTIO PLACENTA
Painless vaginal bleeding Painful vaginal bleeding
Normal uterine tone Hypertonic tender uterus
Patient rarely in labor In labor
Fetal parts usually palpable Fetal parts difficult to palpate
Unengaged Engaged
(-) Toxemia (+) Toxemia
Placenta implanted at the lower Normally implanted placenta
uterine segment

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
- A sudden increase in proteinuria or blood pressure or platelet
count < 100,000/ul in women with hypertension and proteinuria
before 20 weeks gestation

CHRONIC 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
The test should be performed in the morning after an overnight fast of at Low Platelets < 100,000 cells/mm3
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 UTERINE FIBROIDS / LEIOMYOMA
- Max dose: 20 mg IV - Most common neoplasm in women
DOC for maintenance: Methyldopa Types:
DOC for prevention of eclampsia: Magnesium Sulfate 1. Submucous
- Loading dose: 4 g SIVP, 5 g on each buttocks 2. Subseous
- Maintenance dose: 5 g on alternating buttocks q6 x 4 doses 3. Intramural (most common)
- Therapeutic level of MgSO4: 4-7 mEq/L 4. Intraligamentary
10 meq/L: Patellar reflexes disappears Risk Factors:
12 meq/L: Respiratory paralysis 1. Increasing age
>12 meq/L: Respiratory arrest 2. Early menarche
- Antidote: Calcium gluconate 3. Low parity
4. Tamoxifen use
Hypertensive Work-up: 5. Obesity
CBC-PC: sudden decrease in hemoglobin and hematocrit may Signs and Symptoms:
indicate hemolysis; to determine presence of thrombocytopenia 1. Usually asymptomatic
(for the diagnosis of HELLP Syndrome) 2. Abnormal bleeding, usually intermenstrual spotting
Liver enzymes (AST, ALT): for the diagnosis of HELLP Differentials:
Syndrome 1. Pregnancy
LDH: if elevated, may indicate hemolysis 2. Adenomyosis
Bilirubin: if elevated, may indicate hemolysis 3. Ovarian neoplasm
BUN and Creatinine: if elevated, may indicate severe Diagnostics: Ultrasound
preeclampsia Management:
Urinalysis: to determine presence of proteinuria 1. Observation for small, asymptomatic myoma
Serum Na, K, Cl, Mg, Ca, uric acid 2. Myomectomy or hysterectomy depending on the age,
parity, and future reproductive plans
FIGO CLASSIFICATION SYSTEM (PALM-COEIN) FOR CAUSES 3. Medical: GnRH agonists, Danazol, aromatase inhibitors,
OF ABNORMAL UTERINE BLEEDING IN NONGRAVID WOMEN medroxyprogesterone acetate
OF REPRODUCTIVE AGE
OVARIAN NEW GROWTH
Functional Cysts:
- Corpus luteum cyst
- Theca lutein cyst
- Follicular cyst

CERVICAL CANCER SEX-CORD


EPITHELIAL CELLS GERM CELL
- Fifth leading site of cancer for both sexes combined STROMAL
TUMORS TUMORS
- Second most common among women TUMORS
- Risk Factors: HPV infection, Early coitarche, Multiple sexual Serous tumor Teratoma Fibroma
partners, Smoking, OCPs, Low socioeconomic status Mucinous tumor - Mature Granulosa-Theca
- MC Histopathologic Type: Squamous Endometrioid tumor - Immature cell tumor
- Symptoms: Abnormal vaginal bleeding (MC), vaginal discharge, Clear cell tumor Dysgerminoma Sertoli-Leydig cell
pain, urinary incontinence Brenner tumor Endodermal sinus tumor
- Signs: erosion, mass, bulky endocervical canal, anemia, weight tumor
loss, cachexia Choriocarcinoma
- Most important prognostic factor: Stage Embryonal
- Diagnosis: Biopsy carcinoma
- Treatment of choice for all stages: Radiotherapy
- Other treatment modalities: Surgery, Chemotherapy Evaluation of Pelvic and Abdominal Masses Found on Physical
Examination
- Causes of death: Uremia, hemorrhage, sepsis
ENDOMETRIOSIS vs ADENOMYOSIS
ENDOMETRIOSIS ADENOMYOSIS
- Located outside the uterus; - Located at least 2.5 mm
most common: ovary from the basalis
- Caused by retrograde - From aberrant glands of
menses (Sampsons theory: basalis
Ultrasound Findings in Patients with a Pelvic Mass
most popular)
- Responds to cyclic changes - Does not respond to cyclic
changes
- Prevalent in nulliparous - Common in multiparous
(mid-30s) women
- Causes infertility and - Causes dysmenorrhea and
dysmenorrhea menorrhagia
- Diffusely enlarged uterus
- Dx: Laparoscopy, UTZ, MRI - Dx: UTZ, MRI
- Medical Tx: Danazol, GnRH - Medical Tx: GnRH,
agonist Progestogen, cyclic OCPs,
- Surgical Tx: TAHBSO / TAH NSAIDs
with ovaries preserved - Surgical: Hysterectomy

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CAUSES OF FEMALE PELVIC PAIN TRICHOMONAS, MONILIASIS, GRAM STAINING
1. Torsion 1. Prepare materials: cotton-tipped applicator, 3 glass slides,
2. Pelvic inflammatory disease fixative (NSS), gloves, KY jelly
3. Ovarian new growth 2. Introduce self, explain the procedure, ask for OB score, LNMP,
4. Appendicitis history of D&C
5. Endometriosis 3. Place in dorsal lithotomy position, drape the patient, focus the
6. Adenomyosis droplight
7. Acute Appendicitis 4. Wear gloves
5. Wet the vaginal speculum with PNSS
PAP SMEAR 6. Push the posterior vaginal wall with an index finger
used to obtain cells from the cervix for cervical cytology screening 7. Insert speculum obliquely about 45 degrees, then downward
8. Open the speculum and look for cervix, then lock
When to start cervical cancer screening? 9. Get cotton pledget and collect three specimens from the
Age 18 or once sexually active discharge of the cervix
NOT later than 21 10. Prepare 3 slides:
3 years after onset of vaginal intercourse - Trichomonas: NSS
- Moniliasis: KOH
No previous screening, positive cervical cancer history, DES
- Gram stain: Crystal violet, iodine, alcohol, safranin
exposure, positive HIV
Diagnostic Cues for Sexually Transmitted Infections
Patient Preparation:
Cue STI Agent
Refrain from using tampons, birth-control foams, jellies or other Clue Cells Polymicrobial
vaginal creams for 2-3 days before the test.
Fishy odor after Bacterial Vaginosis usually Gardnerella
No need to douche for 2-3 days before the test. Whiff Test vaginalis
No sexual intercourse for 2 days before the test. Granuloma Klebsiella
The best time is at least 5 days after menstrual period stops. Donovan Bodies
Inguinale granulomatis
School of Fish Chancroid Hemophilus ducreyi
Procedure: Intracellular Neiserria
1. Prepare materials: 3 cotton-tipped applicator, 1 glass slide, Gonorrhea
diplococci gonorrheae
fixative (95% ethyl alcohol), gloves, KY jelly
MENOPAUSE
2. Introduce self, explain procedure, ask for OB score, LNMP,
history of D&C - the time when there has been no menstrual period for 12
3. Place in dorsal lithotomy position, drape the patient, focus the consecutive months
droplight - During this period, LH and FSH levels gradually rise because of
4. Wear gloves diminished estrogen production. The fall in estradiol levels
5. Wet the vaginal speculum with PNSS leads to hot flashes, mood changes, insomnia, depression,
6. Push the posterior vaginal wall with an index finger osteoporosis, and vaginal atrophy
7. Insert speculum obliquely about 45 degrees, then downward - Average age: 48 years old (Philippines)
8. Open the speculum and look for cervix, then lock
9. Get cotton pledgets and take specimen from the endocervix,
- Types: Natural or Induced
swab in a Z manner over the 1/3 of the glass slide. Throw the
use cotton pledget.
10. Another cotton pledget for the ectocervix, swab again over the
middle third of the glass slide. Throw the use cotton pledget.
11. Another cotton pledget for lateral vaginal wall, swab again 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 Estrogen Reproductive
Intermediate Progesterone Secretory
Parabasal Androgen Menopause 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
HPV VACCINE 6. Calcium, Vitamin D
Gardasil (Merck) Cervarix (GlaxoSmithKline) 7. Exercise
Quadrivalent Bivalent
Against HPV types 6, 11, 16 Against HPV types 16 and 18 Note: There are also QUESTIONS on
and 18 ETHICAL CONSIDERATIONS in the practice of OB-GYN
Intramuscular Intramuscular Examples: Autonomy, Confidentiality, Principle of Double Effect
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 Read at your own risk.

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