Oral Revalida Review 2019

OBSTETRICS AND GYNECOLOGY

Lecturer: Ana Katrina Rubin-Siton, MD

*NOTE: Please study the trans together with the

lecture slides

PART 1: OBSTETRICS High Risk Pregnancy:

I. General Reminders 1. Extremes of Ages

1. Before doing the complete History and PE, a. Young primigravidas
GET THE VITAL SIGNS FIRST. b. Elderly primigravidas
(pelvic exam cannot be done in a patient with 2. Medical Complications (HTN, DM, CVD,
elevated BP) Asthma, Infection, Malignancies, etc.)
2. Always obtain consent from the patient and 3. Poor Obstetrical History
explain that you are going to do a pelvic a. 2 consecutive abortions
examination. b. 3 or more repeated abortions
3. Assure that the patient has already urinated c. History of preterm delivery
prior to doing the pelvic examination. d. History of term/preterm fetal death in utero
e. History of term/preterm neonatal death
II. FIRST PRE-NATAL CHECK UP f. Previous baby with congenital anomaly
4. Placenta previa
A. HISTORY TAKING
5. Gynecologic tumors
Must Knows! 6. With coexisting trophoblastic disease or has
had one in the last year
1. Get the accurate AOG by computation of the 7. Patients with problems with fetal aging,
LMP structure, and size
NOTE: a. AOG ≥ 41 weeks
b. Fetal macrosomia or IUGR
*Ultrasound is the most reliable tool to detect c. Unsure fetal aging
AOG <12 weeks (early ultrasound) d. Multiple gestation
*If the disparity between the computed AOG by e. Fetal congenital anomalies
LMP and Early UTZ is 2 WEEKS OR MORE, USE 8. Polyhydramnios/Oligohydramnios
THE AOG BY EARLY ULTRASOUND

2. Ask and know whether the cycle is ovulatory

or not 10 DANGER SIGNS OF PREGNANCY
3. Compute for the Estimated Date of Delivery 1. Persistent headache
(EDD): 2. Blurring of vision
Naegele’s Rule: add 7 days to the date of the 3. Nausea and vomiting
first day of the last normal menstrual period 4. Fever and chills
and counting back 3 months 5. Epigastric Pain/Hypogastric Pain
6. Dysuria
4. Classify if the patient is HIGH RISK or NOT 7. Decreased fetal movement
8. Watery Vaginal Discharge
Oral Revalida Review 2019

9. Bloody Vaginal Discharge

10. Nondependent edema/ Swelling of the POSITIVE SIGNS OF PREGNANCY
hands and feet that is non-resolving

Definitive signs that the pregnancy has really

PRESUMPTIVE SIGNS OF PREGNANCY occurred

• Fetal Heart Tones

Signs and symptoms that may resemble
pregnancy but may be attributable to something
TVS 6-8 WEEKS
else
DOPPLER 10-12 WEEKS
• Amenorrhea STETHOSCOPE 18 WEEKS
• Nausea & vomiting
• Fatigue • Perception of active fetal movement by the
• Urinary frequency examiner
• Quickening • Recognition of embryo or fetus by ultrasound
• Uterine enlargement
• Pigmentation changes EXPECTED FINDINGS AGE OF GESTATION
ON UTZ
Gestational Sac 4-5 weeks
Yolk Sac 5-6 weeks
PROBABLE SIGNS OF PREGNANCY Fetal heart beat 6-8 weeks
Crown Rump Length Predictive of
Signs and symptoms that are noted by the
Gestational Age up
examiner, and are more certain implications
to 12 weeks
that the woman is pregnant

• Abdominal enlargement B. PHYSICAL EXAMINATION

• Changes in uterus and cervix 1. Weight
*HEGAR’s sign – softening of the
uterine isthmus Weight Gain: (recorded in pounds)
*GOODELL’s sign –Softening of the
cervix (6-8 weeks)
*CHADWICK’S sign- Vaginal mucosa
usually appears dark bluish red and congested
• Palpation of fetal outline
• Braxton Hicks contractions
• Ballotement (20th week)
*uterus is pushed with a finger to feel
whether a fetus moves away and returns again
• (+) Pregnancy test – β HCG
*Onset: 8-9 days after ovulation
*Peak: 60-70 days (10th -11th week)
*Nadir: 14-16 weeks AOG
Oral Revalida Review 2019
*Weight gain is not expected in the first
trimester because of nausea and vomiting
2. Breast Examination
Do not forget to drape the patient properly
during the examination
3. Abdominal Examination
a. Fundic Height: start at 16-18 weeks until 34
weeks
b. Leopold’s Maneuver: Start at 28-30 weeks
LM1: Fundal grip (what fetal part occupies the
fundus?)
*Head: ballotable mass, small, hard and round
*Buttocks: wider and softer
LM2: Umbilical grip (where is the fetal back?
Landmark to check for the heart tones)
LM3: Pawlick’s grip (what fetal part is lying at
the pelvic inlet?)
*Grasp the part of the fetus above the
symphysis pubis
*May tell if the presenting part is still floating
or already engaged
LM4: Pelvic Grip (what is the presenting part of
the fetal head?)
*Not usually and routinely done
c. Fetal Heart Tones (be guided by the AOG in
doing the appropriate technique to check for
FHT)
4. Pelvic Examination
a. External Genitalia: (done by inspection)
Reporting:
“Hair is distributed in an inverted right triangle
pattern, (+) RMLE episiotomy scar measuring
___cm, no gross lesions”
b. Speculum Examination
Technique:
1. Separate the labia using the thumb and pinky
of your dominant gloved hand to visualize the
urethral opening and the vaginal opening.
2. Avoid the urethra.
3. Insert the speculum downwards and
posteriorly to follow the normal course of the
vaginal vault on a dorsal lithotomy position.
4. Open the blades of the speculum WITHOUT
WITHDRAWING it.
5. Describe the findings.
6. Assess the odor upon withdrawal of the
speculum.
Reporting: ‘’cervix is violaceous, smooth, with
minimal, whitish, mucoid, non-foul discharge’’
NOTE: In lubricating the speculum, use water if
you are going to do Pap smear; otherwise KY
Jelly may be used.
Oral Revalida Review 2019

c. Internal Examination What Kind of Ultrasound?

1. Transvaginal: if <12 weeks AOG
Technique:
2. Transabdominal: if >12 weeks AOG
1. Separate the labia using the thumb and
pinky. C. Fetal biometry (>13 weeks)
2. Insert the thumb first followed by the middle
2. CBC: to get a baseline values for the patient
finger, palm up.
since physiologic anemia is expected in
3. Palpate
pregnancy (see values for pregnant patients)
Reporting: ‘’cervix is soft, long, closed; uterus
enlarged to 2 months size, no adnexal mass or
tenderness’’

d. Bimanual Examination:

Technique:
Start from the umbilicus going down, palpate
the fundus and observe and feel as the cervix
moves down to your examining finger, that
correlates with level of the fundus.
e. Examination of the Adnexa: not done if >12
weeks AOG for the uterus already becomes an
abdominal organ
Technique: Palpate from the ASIS downwards
NOTE: Do not do SPECULUM EXAMINATION in a
patient with no sexual contact; only do rectal
examination if warranted.
f. RECTOVAGINAL EXAM
Technique: Insert the pointing finger inside the
vagina and the middle finger in the anal canal
Indication: to check for the presence of masses
on the cul de sac
3. Blood Typing
4. Urinalysis: to detect asymptomatic
bacteriuria and to rule out any foci of infection
since infection can precipitate abortion (1st half
of pregnancy) and preterm labor (2nd half of
pregnancy)
5. Hepatitis B Screening
6. HIV Screening
7. Vaginal and anal culture for Group B Strep
(35-37 weeks)
3. GDM SCREENING
In all Filipino women, we request FBS right
away on the first prenatal check up

C. PLANS

1. Ultrasound
Uses of Ultrasound:

A. Determine the viability: especially if the AOG

by LMP is <12 weeks wherein Doppler cannot
determine heart tones
B. Disparity between the computed AOG by LMP
and Physical Examination findings (bimanual
examination)
Oral Revalida Review 2019
NOTE: At 24-28 weeks: HPL levels are high
which can increase glucose levels
4. FOLLOW-UP SCHEDULE
 Monthly until 28 weeks (7 months)
 Every 2 weeks until 36 weeks (9
months)
 Weekly 37 weeks onwards
*if high risk, patient’s follow up schedule may
vary
5. MEDICATIONS
1. Folic Acid: given on the first trimester
*Daily intake of 400 micrograms throughout
the periconceptional period
*Can give 4mg month before the conception
and in the first trimester if with previous child
with NTD
2. Ferrous Sulfate: starting second trimester
because it can cause gastric irritation
PART 2: GYNECOLOGY
CHIEF COMPLAINT: VAGINAL DISCHARGE
I. Bacterial Vaginosis
a. Amsel’s Criteria: need to fulfill 3 out of the 4
criteria
 Milky homogenous discharge
 Clue cells
 Vaginal pH > 4.5
 Amine odor with 10% KOH (Whiff Test)
b. Treatment:
Sig: Metronidazole 500mg/tab, 1 tab BID for 7
days
II. Trichomoniasis
a. Speculum Examination: yellowish/greenish
frothy discharge, strawberry cervix
b. Treatment:
Sig: Metronidazole 500mg/tab, 1 tab BID for 7
days (avoid taking alcohol within 72 hours of
the last intake)
NOTE: Trichomoniasis is a sexually transimitted
disease therefore, TREAT THE SEXUAL PARTNER
III. Candidiasis
a. Most Common Presentation: Vulvar pruritus
b. Treatment:
Sig: Fluconazole 150mg/tab OD
CHIEF COMPLAINT: VAGINAL BLEEDING
I. AUB (either oligomenorrhea or
hypermenorrhea)
!!! VERY VERY IMPORTANT IN YOUR LIFE: ‘’AUB
ON THE BACKGROUND OF REGULAR MENSES:
ALWAYS RULE OUT PREGNANCY FIRST’’
*Determine first if the AUB is ovulatory or
anovulatory
1. POLYCYSTIC OVARIAN SYNDROME (PCOS)
a. Diagnosis: use the Rotterdam Criteria, know
also the Ferriman-Gallwey Hirsutism Scoring
b. Treatment/Management
-Lifestyle Modification (CORNERSTONE OF
TREATMENT)
-OCP
-Metformin (only an adjunct treatment)
A. Thickened Endometrium:
Pathophysiology: Estrogen is present in the
patient that’s why there is a thickened
endometrium, and what she lacks is
Progesterone.
Management: PROGESTERONE CHALLENGE
TEST
Sig: Medroxyprogesterone acetate 10mg/tab, 1
tab OD for 5 days
Oral Revalida Review 2019

 How long can you wait for her to 4. Myoma is the cause of the bleeding
bleed? 5. Sarcomatous degeneration
We can wait for 2 weeks for the
3. ADENOYMYOSIS
bleeding to occur
 How will I regulate the cycles? Most common risk factors: multiparity,
Give MPA 10mg/tab, 1 tab OD on Days previous CS, prior uterine surgeries
16-25 of the cycle for 6 months PE: Symmetrically enlarged uterus
Explanation: Day 16-25 coincides with
the secretory phase where
Management:
Progesterone is expected to act and you
a. Medical Management: put the patient on
will try to synchronize the normal
pseudo-pregnancy or pseudo-menopause state
physiologic process by giving
*give OCP WITHOUT THE 7 DAY ‘’NO PILL
Progesterone in the form of MPA
INTERVAL’’: do not make her bleed
 Will I advise her to undergo TVS/TRS
b. Surgical Mangement: TAH/ TAHBSO (non-
after 6 months of treatment?
desirous of pregnancy) vs. Myomectomy (still
NO.
desirous of pregnancy)
Explanation: The cysts in the ovaries
are not expected to regress and what is
more important is that the patient CHIEF COMPLAINT: HYPOGASTRIC PAINS
already has regular menstrual cycles.
Differentials:
B. Thin Endometrium (not estrogen primed):
1. Endometriosis
Management: COMBINATION OCP 2. Pelvic Inflammatory Disease (PID)
a. SE: (+) discharge
Cyproterone Acetate + Ethinyl Estradiol (Althea)
b. IE: (+) cervical motion tenderness: move the
Sig: Take 1 tablet for 21 days straight, no drug
cervix from side to side or up and down
intake for 7 days in order to make her bleed
c. Treatment:
*good for hyperandrogenic presentations (i.e.
*Outpatient:
acne) due to the Cyproterone acetate
Ceftriaxone 250mg IM, single dose +
Doxycycline 100mg PO BID for 14 days
2. MYOMA
± Metronidazole 500mg/tab 1 tab BID for 7
PE: Nodularly enlarged uterus days
Management:
a. Medical management *In-patient:
b. Surgical: TAH/ TAHBSO (non-desirous of
Clindamycin 900mg/IV q8 + Gentamycin
pregnancy) vs. Myomectomy (still desirous of
2mg/kg as loading dose and 1.5mg/kg q8 as
pregnancy)
maintenance dose: better penetrance in
abscesses
*NOTE: Indications to take out a myoma
1. Myoma that is causing pressure symptoms
d. Prognosis: can scar the fallopian tubes and
2. Uterus enlarge to 14 weeks AOG/ 3months
can result to infertility, and ectopic pregnancies
3. Solitary myoma that is 8 cm in size