TOPNOTCH MEDICAL BOARD PREP - COMMON OB-GYN EMERGENCIES

TOPNOTCH MEDICAL BOARD PREP - COMMON MOONLIGHTING EMERGENCIES BY CARLOS PRIMERO GUNDRAN, MD
For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/

GOAL 3: IMPROVE THE SAFETY OF HIGH-ALERT
OB-GYN FOR THE GENERALIST MEDICATIONS
Basic approach to select OB-GYN cases for the • Develop and implement a process to improve the safety of high-
General Practitioner alert medications
1. Anesthetic agents: bupivacaine, propofol, lidocaine, etc.
Christopher Joseph Soriano, MD, MHPEd, FPOGS
2. Antithrombotic agents: streptokinase
3. Anticoagulants: enoxaparin, heparin, warfarin
INTERNATIONAL PATIENT SAFETY GOALS 4. Insulin (SC & IV)
5. Moderate sedation agents
(IPSG) 6. Narcotics/opioids: morphine, nalbuphine, diazepam, etc
Joint Commission International
7. Electrolytes: calcium gluconate, magnesium sulfate, etc

8. Chemotherapy drugs
GOAL 1: IDENTIFY PATIENTS CORRECTLY

• Develop and implement a process to improve accuracy of patient
identifications. GOAL 4: ENSURE SAFE SURGERY
o Ask patient’s name and birthday.
• Develop and implement a process for the preoperative
o Make sure name tag is on the correct patient.
verification and surgical invasive procedure site-marking
o Make sure hospital PIN matches the patient data.

o If unconscious, look for any ID with picture to identify patient.
o If unconscious without any ID, properly tag the patient. Include
any identifying marks e.g. birthmark, scar, tattoo, etc.

GOAL 2: IMPROVE EFFECTIVE COMMUNICATION
• Develop and implement a process to improve the effectiveness
of verbal and/or telephone communication among caregivers.
This is Dr. X. I am
What is the
calling about
situation you
Patient Y who
Situation are calling
consulted here at
about? Reason
ER for (chief
for referral.
complaint).
She is 30 y/o,
female, single,
G1P0, 12 weeks
Pertinent AOG, with 1 day
Background background history of vaginal
information. bleeding. Currently,
no medications &
no prenatal check
up.
Initial She has stable vital

impression signs. Closed cervix
with vital signs, with minimal blood
Assessment physical exam & on speculum.
recent
laboratory
tests.
Would you like me

Suggested plans
or by other to request for CBC & GOAL 5: REDUCE THE RISK OF HEALTH CARE-ASSOCIATED
Recommendation stat TVS?
attending INFECTIONS
physicians.
• Develop and implement evidence-based hand-hygiene
guidelines to reduce the risk of health care-associated infections.
GOAL 6: REDUCE THE RISK OF PATIENT HARM RESULTING

FROM FALLS
• Develop and implement a process to reduce the risk of patient
harm resulting from falls for the inpatient population.

TOPNOTCH MEDICAL BOARD PREP - COMMON MOONLIGHTING EMERGENCIES BY CARLOS PRIMERO GUNDRAN, MD Page 1 of 8
OBSTETRICS • IE: 5 cm, 80% -1, -BOW clear fluid, cephalic; ischial spines not
prominent, sacral promontory not palpable.
LABOR & DELIVERY
1. What is your assessment?

Recommendations for the General Practitioner
BASIC IN-PATIENT ORDERS 2. What are your plans?

• Admit
ASSESSMENT
• Diet
• G1P0 PU 38 weeks AOG cephalic in labor;
• Monitor

• IVF
PLANS
• Therapeutics, etc
• If RTPCR (-): Admit to LR. Secure consent for delivery.
• If RTPCR (+) or pending: Admit to LR Isolation. Level 4 PPE.
LABOR • Diet: May have sips of water or NPO.
ER CONSULT • Monitor vital signs and progress of labor (plot partogram). Hook
• Vida, 28 y/o G1P0 at 37 weeks AOG, came in due labor pain to fetal monitor, intermittently.
(6/10) at irregular intervals. • IVF (Mainline): D5LR 1 liter for 8 hours; (Side drip) D5LR 1 liter
• PMH: unremarkable + 10 units oxytocin to run at 8 to 10 drops/minute. Titrate to
• Vitals: Stable regular contractions.
• FH=30 cm. FHT=150’s. LM3=cephalic • Analgesia: Meperidine 25 mg/IM + Promethazine 25 mg/IM or
• Contractions every 10-20 minutes Nalbuphine 10 mg/IM
• IE: 1 cm, 50% -3, posterior, soft, (+) BOW ischial spines not • Diagnostics: CBC, Urinalysis. (Others: Blood type, HBsAg, HIV,
prominent, sacral promontory not palpable. etc)

1. What is your assessment? • Inform Pediatrician and Anesthesiologist (if applicable)

2. What are your plans?
CONSULT: Health Center with Lying-in Facility
ASSESSMENT • Raquel, 28 y/o G1P0 at 38 weeks AOG, came in due to leaking
• G1P0 PU 37 weeks AOG, cephalic, latent phase of labor. bag of waters.
• PMH: unremarkable. RTPCR swab (-) done last week.
PLANS • Vitals: stable
• Send home (if irregular contractions on monitoring). • FH=32 cm; FHT=140’s;
• Give or update admitting orders. • Contractions every 5-6 minutes, strong.
• Ambulation at home. • IE: 5 cm, 80% -1, -BOW clear fluid, ischial spines not
• Small frequent meals and hydration. prominent, sacral promontory not palpable.
• Monitor: Fetal kicks: 10 kicks in 2 hours • 3rd hour IE: 7 cm, fully effaced, station 0.
• Proceed to Labor Room or ER if: • 5th hour IE: same with caput.

o Contractions: every 3 to 5 mins, strong
1. What is your assessment?
o Vaginal discharge: bloody show or watery discharge
o Decreased fetal movement. 2. What are your plans?
• Therapeutics:
o Check if with recent CBC, urinalysis. Repeat if done more than
1 month.
o RTPCR SARS-COV2 swab (valid for 14 days)
• Medications
o Continue prenatal medications.
o Optional (>37 wks): cervical ripening agents e.g. Evening
primrose oil (EPO) capsule BID to TID/vagina or BID to TID
orally.

ER CONSULT
• Nina, 28 y/o G1P0 at 38 weeks AOG, came in due to leaking
bag of waters.
• PMH: unremarkable
• Vitals: stable
• FH=30 cm. FHT=150’s.
• Contractions every 5-6 minutes, strong.
ASSESSMENT • Came in due to intense labor pains with bloody show.
• G1P0 PU 38 weeks AOG cephalic in labor; Protracted active • FH: 30 cm; FHT: 140’s left side
phase of labor. • IE: Fully, station +4, cephalic, (-) BOW, clear fluid

Observe the Delivery.
PLANS 1. List down positive practices.
• Plan for transfer to Tertiary Facility since no progress for 2 2. Suggestions for improvement
hours. Patient is primigravid.
• Diet: Place on NPO for a possible CS. POSITIVE
• IVF (Mainline): D5LR 1 liter for 8 hours; • Supportive staff
• Analgesia: Meperidine 25 mg/IM + Promethazine 25 mg/IM or • EINC practiced
Nalbuphine 10 mg/IM o Baby out call time
o Immediate drying of baby
CONSULT: Health Center with Lying-in Facility o Skin-to-skin contact
• Dang, 28 y/o G1P0 at 38 weeks AOG, came in due to leaking o Timely cord clamping and cutting
bag of waters for 2 hours. o Non-separation
• PMH: unremarkable. RTPCR (-) done last week. o Placenta out call time
• Vitals: stable
• FH=32 cm; FHT=140’s; RECOMMENDATIONS
• Contractions every 3-4 minutes, strong. • Asepsis & antisepsis
• IE: 2 cm, 50%, posterior, -3, (-)BOW clear fluid, ischial spines • Draping
not prominent, sacral promontory not palpable. • Proper lithotomy
• Local anesthesia
1. What is your assessment? • Restricted episiotomy
2. What are your plans? • Sterility of instruments
• Oxytocin IM after delivery
ASSESSMENT • Gentle cord traction
• G1P0 PU 38 weeks AOG cephalic in labor; PROM

PLANS
LABOR & DELIVERY: SUMMARY
1st Stage 2nd Stage 3rd Stage
• Diet: May have sips of water.
• Monitor vital signs and progress of labor. Hook to fetal monitor, Sips of water or
Upright lithotomy Oxytocin 10u IM
NPO
intermittently (if available)
High-back or Analgesia or Gentle traction of
• IVF (Mainline): D5LR 1 liter for 8 hours; (Side drip) D5LR 1 liter
ambulate Anesthesia cord
+ 10 units oxytocin to run at 8 to 10 drops/minute. Titrate to
regular contractions. Fetal & Labor Asepsis &
Examine placenta
o Antibiotic: Ampicillin 2 gram/IV every 6 hours until delivery. monitoring Antisepsis
o Analgesia: Meperidine 25 mg/IM + Promethazine 25 mg/IM or Amniotomy Proper draping Assess uterus
Nalbuphine 10 mg/IM Check for
Oxytocin drip Straight catheter
• Inform Pediatrician and Anesthesiologist (if applicable) lacerations
No shaving; trim Assess need of
Analgesia
only uterotonics
Bear down as
Antibiotic (PROM)
needed
Restricted

episiotomy
EINC

SITUATION
• 16th hour of labor: IE same (2cm, 50%, posterior, -3; contractions
every 2-3 minutes strong since start of oxytocin drip.

ASSESSMENT
• G1P0 PU 38 weeks AOG cephalic in labor; PROM for 16 hours
• Possible failed trial of labor
OBSTETRIC EMERGENCIES
PLANS NON-INSTITUTIONAL DELIVERY
• Diet: Place on NPO •
25 y/o G2P1(1001) 38-39 weeks based on EDD.
• Monitor vital signs and progress of labor. Hook to fetal monitor, •
Prenatal check-up done at Health Center.
intermittently (if available) •
RT-PCR SARS-COV2 swab done. No results yet.
• Continue oxytocin drip & antibiotic. •
Went to Govt Hospital 1 and 2 but refused admission due to
• Recommend transfer to tertiary facility for possible CS for Failed
unavailability of hospital beds.
Trial of Labor (16-18 hours cut-off). • On transit inside a tricycle, delivered vaginally to a live baby boy.
• ER findings:
DELIVERY AT BEMONC (PRE-PANDEMIC) o Patient seated inside the tricycle holding her baby with cord
CONSULT: BEmONC facility and placenta between her legs.
• Atey, 20 y/o G1P0 unrecalled LMP. o Mother is conscious, coherent.
• No prenatal check-up. • How will you approach this situation?

ER LEVEL: PLANS
• Unknown COVID-19 status: Wear level 4 PPE. • Antibiotic: Ampicillin 2 grams/IV every 6 hours (if GBS +)
• While patient is inside the vehicle. Clamp and cut the cord. Ask • TOCOLYTIC options:
someone to place placenta in a yellow plastic bag. o Dydrogesterone 10 mg/tablet: 1x, 2x or 3x a day.
• Wrap baby in any clothing. Give to nurse to attend to. o Progesterone 100mg or 200 mg capsule: 1x, 2x or 3x a day (PO
• Place mother in a stretcher. Take vitals. or vaginal)
• Examine vagina applying proper aseptic techniques. Check for o Isoxuprine 10 mg/tablet: 1x, 2x or 3x a day (defer if
lacerations. tachycardic)
• Perform bimanual examination to check if there are no other o Nifedipine 30 mg/tab loading dose; then 10 mg/tablet 1x, 2x
fetus or placenta remaining. or 3x (defer if BP <90/60)
• Start IVF: Plain LR or D5LR1 liter for 8 hours. • Complete bed rest with or without bathroom privileges.
• Medication: Oxytocin 10 units/IM
• Advice admission. APPROACH TO MISCARRIAGE
• If DAMA: Give oral antibiotics, uterotonic THREATENED MISSED
(Methylergometrine tablet) and pain relievers • Symptom: vaginal spotting • Symptom: vaginal spotting
• TVS: live pregnancy with or • TVS: Intrauterine demise
PRETERM LABOR without SCH • Labs: CBC, Urinalysis
CONSULT: Health Center • Labs: CBC, Urinalysis • Continue prenatal vitamins
• Moira, 28 y/o G1P0 at 28 weeks AOG, came in due to uterine • Continue prenatal vitamins • Options:
contractions. • Medications: o Medical: Evening
• PMH: unremarkable o Dydrogesterone primrose oil capsule
• Vitals: stable 10mg/tab, OR (TID) or Dinoprostone
• FH=28 cm; FHT=140’s; o Progesterone 100mg or gel. Await spontaneous
• Contractions every 5-6 minutes, strong. 200 mg/cap expulsion. Options: Save
• IE: admits tip of finger; uneffaced, floating, (+) BOW • Other Plans: specimen or Repeat TVS.

o Bed rest. o Surgical: Dilatation &
1. What is your assessemnt? o No sexual contact. Curettage. RTPCR swab
2. What are your plans? (7 days validity)

ASSESSMENT
SPOTTING + ABDOMINAL PAIN
• G1P0 PU 28 weeks AOG cephalic in preterm labor
CASE
PLANS • Vida, 32 y/o, G2P1 (1011), single, consulted because of
• Monitor vital signs and uterine contractions. Hook to fetal vaginal spotting. One week prior to consult, she noted
monitor to document contractions (if available). reddish spotting on her underwear with increasing right
hypogastric pain. She also noted missed menses for 2
• Laboratory tests: CBC, Urinalysis
o Tocolytic: Terbutaline ½ ampule SC (if not tachycardic); give months. Pregnancy tests done twice were positive.
remaining ½ ampule SC after 1 hour if there are still • Claims to have 3 sexual partners. History of Trichomoniasis
contractions. last year.
• Medications (options): • Vital signs: Normal
o Dydrogesterone 10 mg/tablet: 1x, 2x or 3x a day. • PPE:
o Progesterone 100mg or 200 mg capsule: 1x, 2x or 3x a day (PO o Direct and rebound tenderness on the right hypogastric
or vaginal) area. Negative for Psoas sign.
o Isoxuprine 10 mg/tablet: 1x, 2x or 3x a day (defer if • Speculum exam: minimal blood from the cervical os. No
tachycardic) polyps.
o Nifedipine 30 mg/tab loading dose; then 10 mg/tablet 1x, 2x • Internal examination:
or 3x (defer if BP <90/60) o Closed cervix with cervical motion tenderness.

o Right adnexal tenderness on bimanual examination.
CONSULT: Health Center How will you manage this case?
• Moira, 28 y/o G1P0 at 30 weeks AOG, came in due to uterine
contractions. ER LEVEL:
• PMH: unremarkable • PANDEMIC: Wear level 4 PPE.
• Vitals: stable o Options: RTPCR-SARS COV2 Swab (if available); COVID-19
• FH=30 cm; FHT=140’s; Antigen test.
• Contractions every 5-6 minutes, strong. • CBC: Hgb 90, Hct 25, WBC 18, Segs 80
• IE: 2cm, 60%, soft, midposition; station (-) 2, cephalic, (+) • Urinalysis: WBC 10-15, Bacteria-moderate, Epithelials-few
BOW • Blood type: B (+)
• Transvaginal ultrasound:
1. What is your assessemnt? o Complex right adnexal mass measuring approximately 5 cm.
2. What are your plans? Thickened endometrium. Minimal fluid in the cul-de-sac.
Corpus luteum on the right ovary.
PLANS IF SEEN AT HEALTH CENTER: • OPTIONAL Screening tests:
• Refer to Tertiary Hospital with NICU facility. o HBsAg: Non-reactive
• Tocolytic: Terbutaline ½ ampule SC (if not tachycardic); give o HIV: Non-reactivePreeclampsia with SEVERE features
remaining ½ ampule SC after 1 hour if there are still o BP 160/110 beyond 20 weeks AOG
contractions. o Associated with any of the ff:
o Thrombocytopenia: platelet <100,000/ml
PLANS AT TERTIARY HOSPITAL: o Impaired liver function: transaminase levels 2x above normal
• Admit at LR (Isolation) or Maternal High-risk Unit. Consent. o RUQ or epigastric pain
• RTPCR SARS-COV2 swab. o Renal insufficiency: serum creatinine >1.1 mg/dl in the
• For fetal neuroprotection: absence of renal disease
o MgSO4 4 grams/IV diluted in 100 ml of PNSS to infuse in 15- o Pulmonary edema
20 mins as loading dose. D5LR 1 liter + 20 grams MgSO4 to run o Cerebral/visual disturbances
for 1 gram/hour, then D5LR 500 ml + 4 grams MgS04 to run o VDRL: Non-reactive
for 1 gram/hour. • Admit or Refer to hospital of choice.
• For fetal lung maturity: • Secure consent for Exploratory Laparotomy possible right
o Betamethasone 12 mg/IM now then after 24 hours, OR salpingo-oophorectomy.
o Dexamethasone 6 mg/IM every 12 hours for 4 doses. • Inform attending physicians.
• NPO o RUQ or epigastric pain
• Monitor vital signs o Renal insufficiency: serum creatinine >1.1 mg/dl in the
• IVF: D5LR1 liter for 8 hours absence of renal disease
• Skin test to antibiotic 30 minutes prior to OR. o Pulmonary edema
• Inform operating room. o Cerebral/visual disturbances
• Reserve 1 unit PRBC for possible OR use.
LABORATORY TESTS
• CBC with platelet
ECTOPIC PREGNANCY • 24 hour urine protein
Symptoms & signs • Serum creatinine
• Abdominal pain, amenorrhea and vaginal bleeding (classic triad) • Lactate dehydrogenase
• Dizziness, fainting, shoulder pain, pregnancy symptoms (breast • Liver enzymes
fullnes, nausea), passage of tissue • Biophysical profile
• Adnexal & abdominal tenderness, cervical motion tenderness, • NST
adnexal mass, uterine enlargement, orthostatic changes, fever
THERAPEUTICS
Diagnosis Anti-HPN meds for URGENT blood pressure control:
• Urine pregnancy test or serum pregnancy test. • Hydralazine: 5 mg/IV or IM, then 5-10 mg IV every 20-40 mins
• Transvaginal ultrasound. If serum BHCG is 1500-2000 mIU and (S/E: hypotension, headache, fetal distress)
there is no intrauterine pregnancy by TVS. • Nifedipine: 10-20 mg tablet PO, repeat 30 minutes if needed;
• Culdocentesis. If aspirate is non-clotting blood. then 10-20 mg every 2-6 hours (S/E: reflex tachycardia,
headache)
• Refer to OB-GYN Oral anti-HPN medications in pregnancy:
• PANDEMIC: RT-PCR SARS-COV2 SWAB; COVID-19 Antigen • Nifedipine 30-120 mg/day of a slow-release preparation
Rapid Test • Methyldopa 500 mg to 3 grams/day orally in 2 to 3 divided doses
• CBC, blood type and antibody screen
• Insert two intravenous lines on each arm. Sample below: Prevention of convulsions
o Right – 0.9% Sodium Chloride (PNSS) 1 liter for 8 hours, this • Magnesium sulfate
will be the site for possible blood transfusion. o Initial: 4 grams/slow IV in 100 ml of Plain NSS (over 15-20
o Left – D5LR 1 liter for 8 hours to expand volume. minutes) and 5 grams/deep IM on each buttock.
• Antibiotic prophylaxis o Maintenance: 5 grams/deep IM on each buttock every 4 hours
• Reserve 1-2 units of packed RBC properly typed and cross- for 24 hours or IV infusion with MgSO4 running for 1-2
matched, depending on clinical assessment of blood loss. grams/hour in the next 24 hours.

CASE CASE
• Bella, 38 y/o, G1P0 36 weeks AOG, consulted because of • Risa, 40 y/o G6P6 (6006) delivered via NSD at a lying-in few
headache. Non-compliant with pre-natal check-up. hours prior to consult.
• FH: 30 cm, FHT: 150’s • Stretcher borne. Blood soaked diaper.
• BP: 160/90 • BP: 90/60, PR: 100, RR: 22, T: 37.1
• IE: 3cm, 60% -3 anterior soft +BOW • PPE: Flat abdomen, fundus palpable over the umbilicus.

What is your plan of management? • Pelvic exam: Blood clots at vaginal vault.
• IE: cervix – 2 cm dilated with tissue plugging the os. Uterus:
PLAN enlarged to 20 weeks.

• Admit. Secure consent for delivery. What are your plans?

• NPO or sips of water
• Monitor vital signs and fetal heart. POSTPARTUM HEMORRHAGE (PPH)
• IVF: D5LR1 liter x 8 hours
• Labs: Blood Systolic
EBL Heart Signs &
o RT-PCR SARS-COV2 SWAB or COVID-19 Antigen Rapid Test volume BP
(ml) rate symptoms
o CBC & platelet, urinalysis, blood type (%) (mmHg)
o Urine protein-creatinine ratio (UPCR) 500-
10-15 <100 Normal None
o Creatinine, LDH, SGPT, SGOT 1000
• Medications Vasoconstriction,
1000 - 100- Slight
o Hydralazine 5 mg/IV (total 20 mg) 15-25 weakness,
1500 120 decrease
o MgSO4 4gram/IV in 100 ml Plain NSS infused in 15-20 minutes; sweating
then side drip: D5W1 Liter + 20 grams MgSO4 to run at 1500 - 120- Restlessness,
1gram/hour for 24 hours. 25-35 80-100
2000 140 pallor, oliguria
o Mainline IVF: D5LR 1 liter for 8 hours 2000- Anuria, altered
§ Side drip: D5LR1 liter + 10 units oxytocin at 10-20 35-45 >140 60-80
3000 consciousness
drops/minute. Titrate accordingly.

PPH: ETIOLOGY & RISK FACTORS
HYPERTENSION IN PREGNANCY
Etiology
Pathophysiology Risk Factors
PREECLAMPSIA WITHOUT SEVERE FEATURES
• Multiple gestation
• BP 140/90 beyond 20 weeks AOG Overdistended
• Polyhydramnios
• Associated with any of the ff: uterus
• Macrosomia
o With or without proteinuria (new criteria)
o Thrombocytopenia: platelet <100,000/ml • Prolonged labor
Uterine muscle
o Impaired liver function: transaminase levels 2x above normal • Augmented labor
TONE fatigue
o Renal insufficiency: serum creatinine >1.1 mg/dl in the • Prior PPH
(Abnormal
absence of renal disease uterine • Prolonged rupture
o Pulmonary edema contractility) Chorioamnionitis of membranes
o Cerebral/visual disturbances (ROM)
Uterine distortion / • Fibroids (myoma),
PREECLAMPSIA WITH SEVERE FEATURES abnormality placenta previa
• BP 160/110 beyond 20 weeks AOG Uterine relaxing • B-mimetics, MgSO4,
• Associated with any of the ff: drugs anesthetic drugs
o Thrombocytopenia: platelet <100,000/ml
o Impaired liver function: transaminase levels 2x above normal
• Prior uterine MANAGEMENT
Accreta / Increta / surgery • First line medical treatment:
TISSUE Percreta • Placenta previa o Medroxyprogesterone acetate (Provera) 5 to 10 mg/tablet
(Retained • Multiparity once a day for 10 days. OR
products of • Manual placenta o OCP, 2 tablets now and after 12 hours (if no contraindications)
conception) Retained placenta / removal • Alternatives:
membranes • Succinturiate / o Tranexamic acid 1 gram/IV or tranexamic acid 500
accessory lobe mg/capsule, 2 capsules every 6 hours.
• Definitive treatment:
• Precipitous delivery
o Suggest Dilatation and Curettage if CBC and vitals are stable.
• Macrosomia
Laceration of the Not responsive to medical treatment.
• Shoulder dystocia
cervix, vagina or
• Operative delivery SAMPLE DRUG DOSAGES
perineum
• Episiotomy (e.g.
mediolateral) LNG-IUS Once every 5 years
• Deep engagement 1 gram TID-QID during heavy
TRAUMA Tranexamic acid
Extension / bleeding for 3 days.
(Genital tract • Malposition
laceration at CS 200 mg PO TID during heavy
trauma) • Malpresentation Ibuprofen
bleeding for 3 days.
• Prior uterine
Uterine rupture 500 mg PO TID during heavy
surgery Mefenamic acid
bleeding for 3 days.
• Fundal placenta 550 mg Loading dose, then 275
• Grand multiparity Naproxen mg BID during heavy bleeding
Uterine inversion
• Excessive traction for 3 days
on umbilical cord
Medroxyprogesterone 10 mg PO OD-TID on cycle days
Preexisting clotting (MPA) 5-26
abnormalities • History of
Coagulopathy or Norethisterone acetate 5 mg PO TID on cycle days 5-26
(e.g. hemophilia,
THROMBIN vonWillebrands disease, liver disease Danazol 200-400 mg PO daily
(Abnormalities hypofibrinogenemia)
of coagulation) DIC • Sepsis GYNECOLOGIC INFECTIONS
HELLP • Intrauterine demise BACTERIAL VAGINOSIS
Anticoagulation • Hemorrhage CLINICAL
• Fishy-smelling discharge
PPH: GENERAL MANAGEMENT • ASYMPTOMATIC (50%)
• Initial management approach
o Assessment: constant awareness of the hemodynamic status Amsel’s Criteria
as well as evaluation to determine the cause of bleeding. (3 out of 4 features)
o Breathing: administration of oxygen • Vaginal pH >4.7
o Circulation: obtaining intravenous (IV) access and adequate • Presence of clue cells on a gram stain or wet mount of vaginal
circulating blood volume through infusion of crystalloid and discharge
blood products. Second large-bore IV catheter is needed • Thin homogenous discharge
• Notify the blood bank. • Release of fishy odor when KOH is added to the discharge
• Simultaneous, coordinated, multi-disciplinary management
(OB-GYN, anesthesiologist, hematologists, radiologists, nurses,
laboratory and blood bank technicians)
• Preoperative preparedness is important especially for patients
identified as high risk.

GYNECOLOGY
Vaginal Bleeding, Cervico-vaginitis, STDs
APPROACH TO VAGINAL BLEEDING
AUB FIGO Classification 2011

CDC STD Guidelines (2010) for Pregnant Women
• Metronidazole 500 mg/tab BID for 7 days
• Metronidazole 250 mg/tab TID for 7 days
• Clindamycin 300 mg/cap BID for 7 days
• Alternatives:
o Metronidazole 0.75% gel.
o 2% Clindamycin cream
• Routine screening is NOT recommended
• Routine treatment of sex partners NOT recommended.

TRICHOMONIASIS
CLINICAL
• Green-yellow frothy vaginal discharge
DIAGNOSTICS
• Offensive odor
• Physical exam • “Strawberry” cervix
• Pregnancy test • Dyspareunia
• CBC • Vulvovaginal soreness, itching
• Serum ferritin • Dysuria, frequency
• Coagulation test (BT, CT, PT, PTT) • Low back pain
• Thyroid function tests
• Ultrasound (TVS or TRS) – 1st line
• All newborns are given ocular prophylaxis with either 1%
silver nitrate solution, or 1% tetracycline ointment or solution
or 0.5% erythromycin ointment within one hour after birth

CHLAMYDIA
CLINICAL
• Most pregnant women are ASYMPTOMATIC
• 1/3 present with urethral syndrome, urethritis or Bartholin’s
gland infection
• Mucopurulent cervicitis (>50%), which is also a presentation
of gonorrhea

MANAGEMENT
• Normal saline wet mount (flagellated motile organism)
• POGS Clinical Practice Guidelines
o Metronidazole 2 grams single dose. (CDC STD Treatment
Guidelines, 2010)
o Partners should be treated
o Withhold Metronidazole until after the first trimester
• Breastfeeding must be withheld during treatment up to 12-24
hours after the last dose

CANDIDIASIS
MANAGEMENT
CLINICAL MANIFESTATIONS
• Prenatal screening
• Profuse, irritating discharge
• Treatment during pregnancy (CDC STD Guidelines, 2010)
• Discharge is thick, white, curdy
o Azithromycin 1g PO as single dose, DRUG OF CHOICE or
attached to vaginal walls
o Amoxicillin 500mg PO TID for 7 days
• Pruritis, tender, edematous vulva
• Alternatives: Erythromycin base or erythromycin ethylsuccinate

TREATMENT • Sexual partners during the 60 days preceding the onset of
symptoms should be evaluated and treated
• Topical treatment is recommended,

although oral azoles are generally
considered safe SYPHILLIS
• Azole creams: Butoconazole, clotrimazole, miconazole, PRIMARY SYPHILLIS
terconazole (CDC STD Treatment Guidelines, 2010) • Painless chancre
• Only topical azole therapies, applied for 7 days, are • Non-suppurative lymphadenopathy
recommended for pregnancy.

GONORRHEA
CLINICAL
• Mucopurulent discharge
• Disseminated gonococcal infection (DGI), which manifests as
petechial or pustular skin lesions, arthralgias, septic arthritis, or
tenosynovitis

SECONDARY SYPHILLIS
• Macular rash: palmar & plantar
• Patchy alopecia
• Conyloma lata in perineum
DIAGNOSIS • Fever, malaise, headache, arthralgia
• Gram-stain of endocervical discharge reveals intracellular
gram-negative diplococci
• GOLD STANDARD is isolation of organism on a selective medium
such as modified Thayer Martin broth
• NAAT

TERTIARY SYPHILLIS
• If primary or secondary is not treated
• Slow progressive disease
TREATMENT OF UNCOMPLICATED GC INFECTIONS IN
PREGNANCY
(CDC STD Treatment Guidelines, 2010)
• Ceftriaxone, 250 mg IM, single dose or
• Cefixime, 400 mg/tab, single dose or
• Single dose injectible cephalosporin regimens PLUS:
o Azithromycin 1 gram PO single dose OR
o Spectinomycin 2g/IM single dose if allergic to penicillin or B-
lactam antimicrobials
• PLUS treatment for Chlamydial infection, unless it is excluded
DIAGNOSIS REACTIVATION DISEASE
• VDRL or RPR – screening • Results in herpesvirus
• Darkfield examination & direct fluorescent Ab testing of shedding, most recurrent
exudates infection is caused by
• Confirmatory tests: HSV-2
o FTA-ABS, MHA-TP, TP-PA • Lesions are generally
o PCR for amniotic fluid fewer in number, are less
o Sonographic fetal surveillance tender, and shed virus for
shorter periods --- 2 to 5
days --- than those of
primary infection.

MANAGEMENT
• The ACOG DOES NOT recommend routine HSV screening of
pregnant women
• Acyclovir appears to be safe for use in pregnancy (>36 weeks
with recurrence)
• Cesarean delivery is indicated for women with active genital
MANAGEMENT lesions or prodromal symptoms
• Recommended treatement (CDC STD Guidelines, 2010) • Women with HSV may BREASTFEED, if there are no active HSV
o Early syphillis: Benzathine penicillin G as single dose, some breast lesions. Strict handwashing is advised
recommend a second dose 1 week later • Valacyclovir and acyclovir may be used during breast feeding
o >1 year duration: Benzathine penicillin G, IM weekly for 3
doses EMERGENCY CONTRACEPTION
o Neurosyphillis: Aqueous crystalline penicillin G or Aqueous
procaine penicillin
• No proven alternatives to penicillin therapy during pregnancy.
Erythromycin may be curative for the mother only.
• Jarisch-Herxheimer reaction often appears after penicillin
treatment of women with primary and secondary syphillis
characterized by uterine contractions accompanied by late fetal
heart decelerations

HERPES SIMPLEX
FIRST EPISODE PRIMARY INFECTION
• Incubation period of 2 to 10 days
• Classic presentation: papular eruption with itching and tingling,
then becomes painful and vesicular
• Multiple vulvar and perineal lesions may coalesce, inguinal
adenopathy may be severe
• Transient systemic influenza-like symptoms are common (fever,
myalgia, malaise)

END OF OBGYN FOR THE GENERALIST

FIRST EPISODE NON-PRIMARY INFECTION
• Fewer lesions, fewer systemic
manifestations, less pain and
briefer duration of lesions and
viral shedding


TOPNOTCH MEDICAL BOARD PREP - COMMON OB-GYN EMERGENCIES

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TOPNOTCH MEDICAL BOARD PREP - COMMON MOONLIGHTING EMERGENCIES BY CARLOS PRIMERO GUNDRAN, MD

For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/

Initial She has stable vital

Would you like me

GOAL 6: REDUCE THE RISK OF PATIENT HARM RESULTING

1. What is your assessment?

1. What is your assessment? • Inform Pediatrician and Anesthesiologist (if applicable)

• Admit. Secure consent for delivery. What are your plans?

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