UNCLE RAY’S

COOKBOOK

2009-2010
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Uncle Ray’s Cookbook

This book is dedicated to:

Raymond Doucette, M.D.

It is intended to help the OB interns survive, even thrive, in

their first years at the University of Utah.

It is NOT intended to replace required reading, and while it

has been formed with information from likely accurate
sources, neither the accuracy nor the completeness of this
work can be guaranteed.

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TABLE OF CONTENTS

General Intern Responsibilities (When to be Where!) 8

UUMC Board Round Times 8
UUMC OB Days 8
UUMC OB Nights 9
IMC GYN 10
Conferences 12
Off-Service Rotations 13
DECK: Antenatal testing 16
2009 FHT Nomenclature 17
GBS testing and treatment 19
PTL 20
PPROM 21
SAMPLE ORDERS 22
OB Emergencies: NRFHT 24
Cord Prolapse 25
Eclamptic Seizure 25
Postpartum Hemorrhage 26
Blood Products 27
Uterine Inversion 28
Shoulder dystocia 29
Chorioamnioitis 30
Endometritis 31
Postpartum Fever 32
External Cephalic Version 33
Cesarean Sections 34
Instruments (C/S and PPBTL) 35

ISSUES: Antenatal Corticosteroids 37

Thrombocytopenia 38
Recurrent SABs 39
Stillbirth Study 40
Radiologic Exposure 42

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Infection Exposures 43
Vaccinations 47

CLINIC: Schedule 48
Prenatal visit 49
Postpartum visits 52
Age-specific screening 53
Non-STD Treatments 54
STD Treatments 55
Blood-borne STDs 57
PID 57
STD / Infectious Disease reporting 59
Pap Smears 62
Emergent Vaginal Bleeding 64
Ectopic pregnancy and Methotrexate 66
Molar Gestations and GTD 61
Non-Emergent Vaginal Bleeding 62 Urinary
Incontinence 65 Bladder Trials
66
Pelvic Relaxation 67
Pelvic Pain 68
Vulvodynia 70
Endometriosis 71
Infertility 72
Depression 74
Emergency contraception 76
Preoperative visits 77

WARDS: Shortness of breath 81

Chest pain 82
Confusion 83
Fever 84
Electrolytes imbalances and replacement 85
Insulin 87

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Heparin 88
Pressors 90

DICTATIONS:
Guidelines 93
Postpartum Discharge 94
Cesarean section 96
Forceps Assisted Vaginal Delivery 98
Postpartum BTL 99
Laproscopic BTL 100
D&C 102
Clinic note – Annual Exam 103

MISC: Commonly Used Meds in Pregnancy (by group) 106

Commonly Used Meds by anyone (by group) 110
Alphabetical List of Commonly Used Meds 114
PCAs 121
Telephone Numbers 122
Passwords 129
Pager Numbers 126

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General Intern Responsibilities
UUMC L&D Board Rounds:

0645 (Monday through Friday) – sign out by mole

0730 (Saturday, Sunday, and holidays) – sign out by mole
1700 (Friday) – sign out by intern
1730 (Monday through Thursday, Saturday) – sign out by intern
1845 (Sunday and Holidays) – sign out by intern

UUMC OB Days

Morning Notes
The postpartum service is your responsibility.
The OB intern and off-service interns round on every postpartum patient.
The OB Chief should know of problems, complications, and morbid events.

Work rounds start at 0500, may vary depending on size of service.

Board rounds are at 0645 on Labor and Delivery.

Night intern assigns interns to patients – The List is left at the cart.
Sometimes there are patients on 2E – there name should be green on the
board.

Medical students should be available and will need f/u exams and notes.
Teach them well and the dividends will be endless.

You need to know the status/plan for all patients on Labor & Delivery.
No matter who’s following the pt, you are still responsible for that patient!
Divide up the board after board rounds.
The OB intern should take the more complicated patients although make sure
you get enough normal vaginal deliveries too.
Frequently running through the board with folks is very helpful.

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You should also:
 Prepare patients for scheduled procedures
 Keep on top of laboring admissions
 Help triage the OBES (OB Emergency Services) patients
 Do post-op checks 4-6 hrs after procedures
(or sign out late ones)
 Dictates D/C summaries when it’s slow
 Have notes updated for oncoming team
 Carry the post-partum pager
 South Main Clinic – Wednesday AM

South Main Clinic

Wednesday mornings on OB Days. Located at ~3700 South Main.

Things to remember:
 Less is more—always consider cost when ordering tests
(even wet preps in the office)
 No additional ultrasounds unless absolutely indicated
 For suspected pre-eclampsia, LFTS are very expensive.
Consider a 24-hour urine first.
 Take all labs/tests to the lab yourself—don’t leave in room

UUMC Nights “ MOLE”

This is a great rotation to learn a lot and increase your numbers without the
chaos and responsibility of running the board, clinics and rounding. Meet
with your mole team the first night to determine expectations and
responsibilities.
o Prepare the list for AM rounds. Put ALL relevant information on
the list: type of delivery, Gs and Ps, relevant medical conditions,
etc.
o Split the post-partum patients between yourself, the Days Intern,
and any Off-Service Interns.
o Night team should also prepare the charts for the next AM cases.

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GYN AT IMC (for interns)

Morning Notes

Round on your GYN patients and any benign GYN patients admitted over
the weekend or night. You may be assigned patients from the mole. As the
intern, you will cover the ER from 0700 until 1700. OR cases generally start
at 0730. You should be at the hospital in time to round on your patients and
get to the OR (usually 0600-0630 is early enough).

ER/Consults

The intern covers the ER from approximately 0700 until 1700.

Call back immediately. (If scrubbed in, have the circulator call immediately.)

The ED has an on-call attending for GYN hits over a 24 hour period. If they
are on teaching service, the on-call GYN doc may ask the resident to be
involved. If they ar not, then you cannot be involved. If the ED calls you
first, have them call the on-call attending and ask them if they want us
involved (again, IF they are on service).

IF you are unable to see the patient immediately, let them know your
timetable and find out if it can wait until you are available. If you are
unavailable and IF IT IS AN EMERGENCY, call your chief (daytime) OR
your in-house attending (nights).

In-patient GYN consults need to be requested attending to attending. If

called first, refer the requesting doc/resident to your attending. Call a senior
resident and the attending with consults after you’ve gathered your
information. For your learning, see the consults with a senior resident or
attending.

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The “Doc-In-The-Box” attending is an OB/GYN attending who covers the
deck/ER at night for emergencies that other MDs cannot cover.

GYN CONSULTS  OB/GYN “ER” ATTENDING.

OB CONSULTS  PERINATOLOGY ATTENDING.

OR.
The cases are assigned by the Chief Resident. Read before you do a case.
Meet the patient outside the OR room by about 0715. Dictate all your cases
the same day. All patients admitted must have a post-op note written about
4-6 hours after surgery. Keep up with your discharge dictations. Whoever
operated on the patient is responsible for the discharge summary.

Have the attending sign the prescriptions and discharge forms for any
patient from an outpatient case—you won’t see them again once they
leave the OR.

L&D. You may be asked to cover the deck when the R2 has clinic etc. On
Labor & Delivery, we follow Perinatal Patients and any high risk (private)
patients we are asked to see. Be aware of the IHC Midwife patients
(perinatology is their back-up) and be available if you are asked to help.

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Conferences

Grand Rounds (alternate IMC, LDS and UNIV):

Wednesday, 0730-0830

GYN Conference (UNIV teams only, Warenski Room @ UUMC):

Thursday, 0730-0830

M&M / Resident Didactics: (Warenski Room @ UUMC):

Thursdays, 1430 - 1730

Perinatal Conference (UNIV teams only, Warinski Room @ UUMC):

1st and 3rd Fridays, 0730-0900

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OFF–SERVICE MONTHS

Ultrasound:
Contact: Dr. Nancy Rose
Perinatology Clinic at IMC
Hours will be 8:30ish to 4:30ish.

Dr. Nancy Rose is your contact person for the rotation, but you will work
with all of the attendings in clinic. Be nice to the techs and support staff—
they will make your life better and they are great teachers of basic skills and
measurements.

Round in the morning on post-partum patients (arrive 5:30am) with the R2

team and then attend ultrasound clinic. The list of patients will be in the
resident room on the desk each day. Check back in later in the day to help
wrap up all errands before sign-out (about 4:30).

Emergency Medicine:
Contact: Sarah Stanley 587-7653

UUMC (1st floor) – call ahead and make sure badge will work.
Sarah will have the schedule ahead of time, it changes month to month, and
you can make day-off requests if you contact her early enough.

Shifts are usually 8, 10 or 12 hours, working about 20-22 shifts.

Family Medicine:
Contact: Dr. Os Sanyer or Dr. Richard Backman
Madsen Clinic 581-8000

Sugharhouse Clinic 581-2000

Call dept a few weeks ahead for scheduling:
-- know what days you’ll be in Clinic 4
-- know what days you’ll need/want off

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Medicine Wards / MICU:
Contact: IM Program Secretary 581-7899

Talk to them a couple months in advance to make sure you get a Gen Med
wards team (ie, NOT Cards or Pulm) and call Clinic 4 to work out your
clinic schedule sooner than later.

Wards call is q4 with one day off per week.

MICU call is q3 with every 6th day off.

MICU days start at 0745, no prerounding necessary.

Don’t worry you can do it!

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THE DECK

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Antenatal Testing
ACOG Educational and Technical Bulletin No.188, January 1994

Indications for Testing

• Decreased fetal movement
• Hypertensive disorders
• Diabetes mellitus (insulin treated)
• Oligohydramnios
• IUGR
• Postdate pregnancy (42 weeks or more, yet, in Utah we seem to test at
41+)
• Isoimmunization (moderate to severe)
• Chronic renal disease
• SLE
• Maternal cyanotic heart disease
• Hemoglobinopathies
• Previous unexplained fetal demise
• Multiple gestation with discordant growth
• Hyperthyroidism

Testing usually begins about 32-34 weeks of gestation, yet may begin as
early as 26 weeks.

The NST, CST, BPP all have very few false-negative results.

NST (Non-Stress Test)

• Observe for fetal heart rate accelerations peaking at least fifteen beats per
minute above the baseline and lasting fifteen seconds from baseline to
baseline.

• Can continue for forty minutes or longer

• Acoustic stimulation of the fetus to elicit an acceleration is valid

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2009 FHT Nomenclature

Baseline: Round to the nearest 5 given average over 10 min window

Need at least 2 min of baseline
Go back further if needed

Variability:
 Absent = undetectable
 Minimal = 1-5
 Moderate = 6-25
 Marked = >25

Accelerations:
 15x15 when EGA >32wks, otherwise 10x10
 Rise to peak in <30 sec
 “Prolonged” if >2min, or baseline change if >10min

Decelerations:
 “Variable” drop to nadir in <30 sec; Last 15 to 120 sec
 “Early” nadir when CTX peaks
 “Late” nadir after CTX peaks
 “Prolonged” last >120 sec but <10 min
 “Sinusoidal” occilate at 3-5 per min for >20 min
 “Recurrent” occur with >50% of CTXs in 20 min window
 “Intermittent” occur with <50% of CTXx in 20 min window

Category I Category II Category III

Baseline normal Brady w/ variability Bradycardic or
At 110-160 Or tachycardic tachycardic
Mod variability Absent/Min/Marked Absent variability
No Lates/Variables Recurrent: Recurrent:
(+/-) Early decels Variables, Lates, or Variables or Lates
(+/-) Accels Prolonged
(+/-) Reactive (-) Accels
= NL acid/base status = Interdeterminate

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CST (Contraction Stress Test)

• Negative-no late decels

• Positive-late decels following 50% or more of the contractions EVEN IF

THE CONTRACTION FREQUENCY IS LESS THAN THREE IN TEN
MINUTES

• Suspicious-intermittent late or significant variable decels

• Unsatisfactory-fewer that three contractions per ten minutes or a poor-

quality tracing

BPP -- Biophysical Profile

(Two points for each)

• Reactive NST

• Fetal breathing movements

(1 or more episodes of rhythmic fetal breathing lasting 30 sec in 30 min)

• Fetal movement
(3 or more discrete body or limb movements within 30 minutes)

• Fetal tone
(1 or more extensions of a fetal extremity with return to flexion)

• AFI (1 pocket at least 2x2 cm or four quadrant sum >5)

Score: <4 Abnormal

6 Equivocal  fetus re-tested in 12-24 hours
8-10 Reassuring

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GBS Testing and Treatment:

Check vaginal swabs on ALL 35-37 week IUPs UNLESS:

a) GBS bacturia in THIS pregnancy
b) Previous infant bacteremia

Always give prophylaxis for:

a) current GBS bacturia
b) previous infant GBS bacteremia
c) Positive GBS on vaginal swab
d) UNKNOWN GBS AND…
 delivery preterm ( < 37 weeks)
 ROM > 18 hours
 Temp > 38.0

GBS Prophylaxis

Pen G 5 million units IV load

Then 2.5 million units IV q4 hrs until delivery

* ideally, get 2nd dose in prior to delivery

ALT: Ampicillin 2g IV load, then 1g IV q4 until delivery

PCN ALLERGIC? If you know ahead of time, get susceptibilies!!

A. Low risk of anaphylaxis:

Cefazolin 2 g IV load, then 1g IV q8 until delivery

B. High risk of anaphylaxis:

Clindamycin 900mg IV q8
Or Erythromycin 500 mg IV q6
Or Vancomycin 1g IV q12

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PTL

Etiology?
Infection (wet prep, cervical cx, GC/CT)
• Cervical
• Decidual
• Amniotic fluid
• Fetal
• Other infections (UTI ,appy, gastroenteritis)

Placenta
• Infarct (multiple small, large “stroke”
• Maladaptive: blood vessels not responding appropriately to
growth
• Abruption
• Previa

Uterine surgery or anomaly

Cervical trauma, previous surgery, “incompetence”
Major maternal illness
Amniotic fluid: PPROM, polyhydramnios
Uterine distension : multiple fetuses
Hormonal “permission”
Idiopathic

Special documentation:
EFW (Perform BSUS if no recent scan)
Presentation
Delivery plan
NBICU Consult
Make sure there is a recent ultrasound, if not, perform a bedside ultrasound.

Treatments may include:

 Nifedipine 20mg q30min x 4 then q6hrs up to ~36 weeks
 Indocin 100mg PO then 50mg q6hrs x 48hrs up to ~32wks

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PPROM

Etiology?
Infection (wet prep, cervical cx, GC/CT)
• Cervical
• Decidual
• Amniotic fluid
• Fetal
• Other infections (UTI,appy,gastroenteritis)
Placenta
• Infarct (multiple small, large “stroke”
• Maladaptive: blood vessels not responding appropriately to
growth
• Abruption
• Previa

Uterine surgery or anomaly

Cervical trauma, previous surgery, “incompetence”
Major maternal illness
Amniotic fluid: PPROM, polyhydramnios
Uterine distension : multiple fetuses
Hormonal “permission”
Idiopathic

Special documentation:
EFW (Perform BSUS if no recent scan)
Presentation
Delivery plan
NBICU Consult
Make sure there is a recent ultrasound, if not, perform a bedside ultrasound.
Discussion with the patient regarding risks of cord prolapse, infection,
abruption, labor with delivery of a premature infant, sudden/unexplained
fetal death.

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SAMPLE ORDERS
L&D Admit:
Admit L&D for IVF / EFM / TOCO
LR 125 mL/hr
CBC, hold clot *
Anesthesia consult prn
Fentanyl 50-100 mcg Q1 hour PRN

* for scheduled CS, VBACs, PIH, Rh negative, or other complicated pts,

order T&S (not hold clot)

PTL:
As above, plus…
CBC with diff, U/A, consider tox screen, cultures
No tocolysis if > 34 wks
Some will give BMZ12 mg IM q24hrs x 2 after 34 wks in absence of infxn
PCN for GBS prophylaxis if status unknown (after obtaining cultures, U/A
as above)
FFN (only if no intercourse or SVEs within 24 hours)
NBICU consult
Formal US

PPROM:
As above, plus
CBC with diff, U/A, consider tox screen
No tocolysis
Some will give BMZ 12 mg IM q24hrs x 2 up to 34 wks in absence of infxn
For latency, some will give erythromycin +/- ampicillin
 Ampicillin 2g IV q 6hrs x 48 hrs
 Erythromycin 250mg IV q6 hrs x 48 hrs
 Amoxicillin 250mg PO TID x 5 days
 Erythromycin-Base 333mg PO TID x 5 days
NBICU consult
Formal US

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Transfer to Antepartum Status:

Transfer: to 2E/2N, antepartum service

Attending:
Resident:
Diagnosis:
Condition: stable
Vitals: q4hours with FHT qshift
Activity: (depends on condition)
Strict HBR with BRP vs wheelchair ride daily)
Allergies:
Nursing: wt/U/A qMon,
NST 2x/week or daily (if PPROM/abruption)
Diet: select
IVF: HLIV
Meds:
Tums 2 g po q2h prn,
Maalox 30 mL po q6h prn,
PNV one po daily,
Docusate 100 mg po bid prn
Labs: (if previa or other indication for CS keep T&S up to date)
Call HO (list #) for:
T>100.4
vaginal bleeding,
loss of fluid,
contractions > 6/hr,
SBP>160,
DBP>90
Sats < 90%

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OB EMERGENCIES
Non-reassuring Fetal Heart Tones (NRFHT)

Etiology is important! Hyperstimulation? Maternal seizure? PIH with abrupt

drop in maternal BP after hydralazine? Prolapsed cord?

1. Position pt to far left or right lateral decubitus.

2. Mask Oxygen at 6-8 L/min
3. While getting sterile glove/lube, check maternal vitals – may be
hypotensive from epidural and anesthesia may need to dose ephedrine.
4. If hyperstimulation – PIT off! Ask RN for terbutaline.
0.25 mg SQ q 20 minutes (hold for pulse > 120)
5. CHECK CERVIX! – Completely dilated? Rapid descent? Prolapsed
cord?
6. Place internal monitors if necessary.
7. Attempt scalp stimulation
8. Consider scalp pH
9. Consider amnioinfusion for variables – do not use if FHT overtly non-
reassuring! 10-20cc/min NS via blood warmer to max 500cc,
maintenance 1-3 cc/min, stop if resting uterine pressure >25-30 mmHg
10. If post-seizure, give the baby time to recuperate.

If not post-seizure, and the fetal HR is less than 100 for 4 to 5 minutes, move
to the OR for observation and C/S if the fetus does not recover.
(Vacuum/forceps if applicable)

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Cord Prolapse

Keep head elevated off the cord – do not remove your hand!
Immediately ask for senior help and notify anesthesia.
Explain to patient what is happening and proceed to the OR.
Consider asking RN for foley placement to instill NS into bladder to assist
with elevating head (and pre-op).
Also consider knee-chest position, trendelenberg.
Usually a C/S is indicated unless baby is “readily deliverable”.

Eclamptic Seizure

Roll to side, pad/protect, but DO NOT put anything in mouth!

Magnesium 5 gram IM each hip
Magnesium 4-8 gram IV
Diazepam 10 mg IV/PR (HAVE ANESTHESIA PRESENT)

REMEMBER:
IV drip Magnesium used on L&D is 4% solution, 4grams/100cc.
The IM solution is a 50% solution, 50 gram/100cc.
IF YOU HAVE A 50% IM SOLUTION AND YOU WANT TO GIVE IT
IV, DRAW 8 CC (four grams) of the 50% solution and ADD 12 CC of NS
and give SLOW IVP.

*** Follow fetal recovery; a seizure IS NOT an indication for a C/S.

Magnesium Toxicity:
Calcium gluconate 1000-2000mg (10-20 mL) IV, Rate 0.5-2 mL/min

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Postpartum Hemorrhage (PPH)

RISK FACTORS: Previous PPH

Previous C/S
Coag abnormality
Uterine surgery
Uterine distention
Uterine malformation
Fibroids
Preeclampsia (on MgSO4)
IAI
Abruption
Placeta previa
Uterine relaxants (terb, NO2)
Prolonged labor or Pit augmentation
Retained POC
General anesthesia

1. IV access (x2 if severe), help from extra nurse and resident. Always think
about sending a T/S, CBC, and coags; contacting anesthesia; and
moving to the OR…..depends on the amount of bleeding, length of
time, and patient’s status. Get fresh set of vitals immediately.

2. Uterine massage-bimanual
 Pain meds if needed: morphine 2-4mg IV x 1
 If uterus is firm, inspect for lacerations: perineum, vagina, cervix. If
no lacerations and uterus is firm, think about retained POC vs.
coagulopathy vs. clots vs. AFE (especially if respiratory symptoms).
 If uterus boggy:

Pitocin (oxytocin) 40u/500cc

Cytotec (misoprostol) 800 mcg PR
Methergine (methylergonovine) 0.2 mg IM q20-30
(avoid if HTN or CAD) (x 2-3 doses)
Hemabate (carboprost tromethamine) 0.25 mg IM q 15min
(avoid if asthma, renal, liver or heart dz) (x 8 doses)

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BE IN THE O.R. BEFORE YOU NEED TO:
 D&C
 Ligate uterine arteries
 Ligate ovarian arteries
 Embolization
 C-hysterectomy)

Follow hemodynamics, blood loss, and patient’s temperature.

Document the event in the chart.

BLOOD PRODUCTS:

Order: What: Volume/Expect: Indication

PRBC RBCs 1 unit = 250-300cc Hemorrhage

plasma removed ↑Hct 3%

Plts Plts only 1 unit = 50cc Plts < 20k (stable)

↑ Plts 6K Plts < 50k (bleeder)

FFP Fibrinogen 1 unit = 150-200cc DIC

Factors 2,7,10,11,12 ↑fib 10mg/dL transfused > 4 units
Heat labile 5 and 7
*Takes 20-30 min to defrosted, then good for 1 hr

CRYO Fibrinogen 1 unit = 10cc Only give in DIC

= 2g non-pregnant pts
↑Fibrin > 70 Emergent < 100

FACTOR VIIa: 1) activates tissue factor

2) binding activated platelets
3) must have normal pH and Temp
4) risk of thromboembolic event ~ 1%

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* After 2-3 liters of LR, consider transfusing one unit PRBC.

* After 4 units of PRBCs, give 1 amp Ca2+ gluconate and consider FFP.

* After 10 units of PRBC, consider platelets and/or cryo if fibrinogen is

low.

Uterine Inversion

Usually massive bleeding.

1. Make sure you have IV access, have clerk order T/S and call anesthesia
and OB attendings.

2. Attempt replacement: “last out, first in” with gentle rotation. If unable to
replace, quickly move to OR.

3. Give uterine relaxants: terbutaline 0.25 SQ, nitroglycerine (anesthesia),

halothane (anesthesia).

4. May need to surgically replace.

5. Follow hemodynamics, blood loss and temperature.

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Shoulder Dystocia

Know the turtle sign (recoil of head

onto perineum).Tell patient to stop pushing. It is helpful if you have an FSE
so you don’t panic.

Help! Get extra help in the room. Anesthesia, Peds, mark the time.

Episiotomy. Generous.

Legs up. McRobert’s maneuver-legs all the way up onto the patient’s chest
to open the AP diameter.

Pubic pressure. One assistant pushing on the pubic area at a slight angle
attempting to rotate the anterior shoulder, while the operator is trying to
rotate the posterior shoulder.

Posterior shoulder. Try to deliver the posterior shoulder.

Extend the fetal arm. If unable, see if you can break the clavicle (pull away
from the lung).

Replace the head and do a C/S. Zavenelli maneuver.

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Chorioamnionitis

GBS prophylaxis:

Pen G IV 5mu then 2.5 mu q4

… OR Amp IV 2g q6 or 2g then 1g q4
… OR Gent 1.5mg/kg q8
… OR Clinda 900mg IV q8
… OR Erythro 500mg IV q6
… OR Cefazolin/Cephalothin 2 gm IV then 1gm IV q6
… OR Vanco 1 gm IV q12

Mandates fetal delivery, regardless of EGA, vaginally if FHT reassuring.

NSVD  ABX in labor and (+/-) continue for 24hrs postpartum

 Ampicillin 2g IV q6hrs
 Gentamycin 100-120mg IV q8hrs OR 5mg/kg IV q24hrs

C/S  Continue Amp/Gent and add Clinda (“triples”) for anaerobic

coverage and continue 48hrs postpartum
 Clindamycin 900mg IV q8hrs

However, many abx regimens are appropriate:

Unasyn (Amp/Sulbactam) 3g IV q6hrs
OR Cefoxitin 1-2 gm IV q4-8
OR Cefotaxime 1-2 gm IV q4-12
OR Primaxin
OR Ticar +/- Clavulanic Acid
OR Pip +/- Tazo (Zosyn)

KEEP IN MIND:
For anaerobic coverage: Clinda or Flagyl.
Triples do not cover Chlamydia!
Amp covers enterococci—cephs, clinda, gent DO NOT.

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Endometritis

Pain out of proportion to normal in the post-partum period, fevers >38.0,

elevated WBC (usually >14).

 Obtain cervical culture if possible, send for Strep A culture.

 Send blood cultures if spiking a temp

 Initiate therapy with Unasyn (3g IV q 6 hours) or

Amp/Gent/Clinda

 Follow CBC, exam closely until 48 hours afebrile

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PostPartum Fever

Definition: 2 temps >38.0 at least 6 hours apart or 1 temp >39.0

Examine Pt!

Consider: CBC/diff
U/A with Cx
Blood Cx
CXR

Causes (The seven W’s):

• Wind (atelectasis, pneumonia)  Incentive Spirometer and/or ABX

• Water (UTI)  ABX

• Wound (incisional infection, cellulitis)  open incision and/or ABX;

Consider Dicloxacillin or Keflex

• Walking (DVT)  LE duplex scan

• Wonder Drugs (meds)  D/C abx?

• Womb – (Endometritis)  if NSVD, get cultures! (See Next Section)

<1% of NSVDs
15% of non-labored C/S
30% of labored C/S

• Wobbies – (breasts engorgement or mastitis)  ABX? (Dicloxacillin)

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Preparing for External Cephalic Version

1. Bedside ultrasound to confirm presentation, fetal head is flexed, back

position, AFI.

2. Have patient on the monitor to obtain a reactive strip

3. CBC, T/S, IV, Terbutaline 0.25mg SQ at bedside

4. Anesthesia consult

5. Consent to be signed (risks of labor, rupture of the bag of waters,

abruption, fetal intolerance and/or distress, need for emergency cesarean
section).

Preparing for Cesarean Section (ELECTIVE)

1. Anesthesia consult

2. IV, T/S, CBC

3. Complete admit H&P and post-op orders

4. Consent. The attending’s name goes at the top of the consent. See “Sample
Consents”. Some people list all the risks (pain; infection;
bleeding; damage to bowel, bladder, nerves, vessels, internal
organ; need for further surgery including hysterectomy with
subsequent loss of fertility; damage to fetus; death) and others do
not.

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Cesarean Instruments

Usually, it is the intern’s job to consent, prep, and place foley catheter.
If you do not know the instruments and when to call for them, your
assistant will assume you do not know.
Memorize the list and know what to do with them.

Rat-tooth pick-up (test anesthesia)

Two dry laps and the scalpel (cut down to fascia, score in the midline)
Goulet retractors (to your assistant)
Mayo scissors and rat-tooth pick-ups (extend fasciotomy laterally)
Kocher clamps (x2) and Mayo scissors (dissect fascia off rectus muscles)
Richardson retractor (to your assistant)
Two snaps (same as small curved kelly clamps - to isolate peritoneum)
Metzenbaum scissors (enter peritoneum)
Bladder blade (central delee) and Richardson retractor
Russian pick-ups and Metzenbaum scissors (vesicouterine peritoneum)
Scalpel (hysterotomy)
Bandage scissors (extend hysterotomy)

(Deliver baby)

Bulb suction, kelly clamp, cord clamp and scissors

(Obtain cord blood and deliver placenta, then exteriorize the uterus)

Wet lap (around uterus) and dry lap (clearing all clots and debris)
Ring forcep (possibly need for bleeders laterally/anteriorly)

#0-Chromic (surgigut) or #0-Vicryl and Russians (closing hysterotomy)

#0-Vicryl (polysorb) and rat-tooth pick-ups (closing fascia)

If pt is obese and subcuticular layer is >3 cm, consider re-approximating

subq with 3-0 Chromic or 3-0 Vicryl.

Staples or 3-0 Vicryl (polysorb) for closing the skin subcuticularly

33
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Postpartum Tubal Ligations-Instruments

Sometimes there’s no scrub tech, so we set up ourselves.

Two Allis clamps

Knife
Mayo Scissors
Army-Navy Retractors
Babcock clamps x 2
(Have a tight sponge-stick available)
#0 plain gut
Mosquito clamp (small kelly)
Suture scissors
Metzenbaum scissors
Kocher clamps
#0-Vicyl (polysorb) and rat-tooth pick-ups
#4-0 Vicryl (polysorb) and Adson pick-ups

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SELECTED OBSTETRIC ISSUES

35
 - 36 -15336
Antenatal Corticosteroids
ACOG Committee Opinion No. 210, October, 1998

Giving steroids is based on likely spontaneous preterm delivery within 7

days or complications likely to lead to a decision to perform delivery within
7 days.

The committee supported NIH Consensus Panel Recommendations

• The benefits of antenatal administration of corticosteroids to fetuses at
risk for preterm delivery vastly outweigh the risks. These benefits include
not only a reduction in the risk of RDS but also a substantial decrease in
mortality and intraventricular hemorrhage.
• All women between 24 and 34 weeks of pregnancy at risk for preterm
delivery are candidates for antenatal corticosteroid therapy.
• Fetal race, gender, and availability of surfactant therapy should not
influence the decision to use antenatal corticosteroid therapy.
• A patient eligible for therapy with tocolytic agents also should be eligible
for treatment with antenatal corticosteroids when she requires repetitive
intravenous tocolytics.
• Treatment should consist of either two doses of 12 mg of betamethasone,
IM, given 24 hours apart or four doses of 6 mg of dexamethasone, IM,
given 12 hours apart. Optimal benefits begin 24 hours after initiation of
therapy and last 7 days.
• Because treatment for less than 24 hours still can result in significant
reduction in neonatal mortality, antenatal corticosteroids should be given
unless immediate delivery is anticipated.
• Antenatal corticosteroid use is recommended in women with preterm
premature rupture of membranes at less than 30-32 weeks of gestation in
the absence of clinical chorioamnionitis because of the high risk of
intraventricular hemorrhage at these early ages.**
• In women with complicated pregnancies for whom delivery before 34
weeks of gestation is likely, antenatal corticosteroid use is recommended
unless there is evidence that corticosteroids will have an adverse effect on
the mother or delivery is imminent.

** Recent evidence suggests benefit in PPROM as late as 34 weeks.

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Thrombocytopenia in Pregnancy
From a lecture by Bob Silver, MD

Destruction of platelets can be autoimmune (usually resulting in spherocytes

on a peripheral blood smear) or microangiopathic (schistocytes on smear).

Differential Diagnosis for Thrombocytopenia in Pregnancy

o 70%-“Gestational” Incidental thrombocytopenia of pregnancy.

(MILD  platelets>75k. Not clinically significant.)
o 20%-PIH.
o Pseudothrombocytopenia-IgG/cold induced
o Drug induced
o Other diseases: HIV, SLE, HepC, Antiphospholipid Ab Syndrome

ITP: Autoimmune, more common in women than men, with IgG-coated

platelets and NO SPLENOMEGALY. If one did an unnecessary bone
marrow aspirate for this condition, one would see normal
megakaryocytes.
TX: IVIgG, splenectomy, platelets, steroids (60 mg qd x 3 weeks).
*If platelets<50K, tx with steroids (70% success).
*Surgery is risky; if platelets<20K, spontaneous bleeds can occur.
*THE ANTIBODIES CAN CROSS THE PLACENTAL AND CAUSE
FETAL THROMBOCTOPENIA (5-38%).

HUS: (hemolytic uremic sundrome) Microangiopathic hemolysis. Renal

insufficiency, hemolytic anemia, and low platelets. Usually postpartum.
Treatment: supportive therapy and fluid management/dialysis.

TTP (thrombotic thromocytopenia purpura) Microangiopathic hemolysis.

Fever, neurologic symptoms, hemolytic anemia, renal insufficiency,
low platelets and LDH 10,000-20,000. Usually earlier in pregnancy.
Do not give heparin, dDAVP, or platelets as these will increase
microthromboses.
Treatment: plasmaphoresis.

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Recurrent SAB, Second Trimester Loss, and Thrombophilias

Autopsy
Placental culture and pathology
Karyotype (cubic centimeter of placenta at the cord insertion, or nuchal
tissue, or part of fascia lata, to Cytogenetics)
KB
RPR
Special Labs: SEE BELOW!

Check for other thrombophilias if h/o clot OR family history.

Tox screen
IF symptomatic: TSH, glucose.

GREAT DEBATE OVER WHAT LABS, IF ANY,

SHOULD BE ORDERED:

Commonly:
1. Lupus anticoagulant panel #30181
2. Cardiolipin Abs (IgG & IgM) #99344
3. Beta-2 glycoprotein I “microglobulin” IgG & IgM
(#50321)

* At a minimum these tests should be done TWICE, 6-8

weeks apart, because a low to mid positive level can
be due to viral illness

Less Commonly:
* Protein C & S (if not pregnant) (#30113/30114)
* Antithrombin Gene III deficiency
* Factor 5 Leiden deficiency (#97720)
* Prothromin 22-10 gene mutation (#56060)
* MTHFR deficiency (#55655)

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 - 39 -15339
STILLBIRTH STUDY (SCRN)

Dr. Silver has included the following labs into the current stillbirth
workup:
 
Lupus anticoagulant                                  # 30181  (blue top)
Cardiolipin antibody (IgG / IgM)          # 99344  (SST)
Kliehauer-Betke                                        # 40105  (purple top)
Indirect Coombs                                        # 10004 (1 - 10ml red top)
RPR                                                           # 50471  (5ml lavender top)
HbA1c                                                       # 80453  (tall lavender top)
Urine toxicology                                         # 90500
Parvovirus serology B-19 antibodies # 65120  (SST)
(acute IgG/IgM)    
 
At delivery, try to obtain:
1.  Study cord blood  (lavender top)
2.  Placenta to pathology
 
Participation in the SCRN study allows payment for autopsy,
chromosome analysis and placental pathology.
 
Autopsies at PCMC require physician signature.
 
SCRN Team can be reached by paging:  339-5011
 
Patient information pamphlets and consent form for autopsy are
available.
 
Kristi Nelson, RN, Clinic coordinator
Elaine Taggart, RN, Study nurse
Michelle Thompson, RN, Study nurse

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Indications for Testing for Antiphospholipid Antibodies
ACOG Technical Bulletin No. 244, February 1998

• Unexplained fetal death or stillbirth

• Recurrent pregnancy loss (three or more spontaneous abortions with no
more than one live birth, or unexplained second or third trimester fetal
death)
• Severe pregnancy-induced hypertension< 34 weeks gestation
• Severe fetal growth restriction or other evidence of uteroplacental
insufficiency in the second or early third trimester
• Nontraumatic thrombosis or thromboembolism (venous or arterial)
• Stroke (especially in individuals < 50-55 yrs)
• Autoimmune thrombocytopenia
• TIAs or amaurosis fugax (especially in individuals < 50-55 yrs)
• Livedo reticularis
• Hemolytic anemia
• SLE
• False-positive serologic test for syphilis

40
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Estimated Fetal Exposure From Some Common Radiologic Procedures

ACOG Committee Opinion No. 158, September, 1995

PROCEDURE FETAL EXPOSURE

(rad=energy/kg/tissue)
CXR 0.02-0.07mrad
Abd. Film (one view) 100 mrad
IVP > 1 rad
Hip flim (one view) 200 mrad
Mammogram 7-20 mrad
Baruim enema or small bowel series 2-4 rad
CT of head or chest < 1 rad
CT of abdomen or lumbar spine 3.5 rad
CT pelvimetry 250 mrad
V/Q scan 50 mrad

Fetal risks of anomalies, growth restriction, or abortions are not increased

with radiation exposure of less than 5 rad, a level above the range of
exposure for diagnostic procedures. Yet, it is estimated that 1/2000 children
exposed to ionizing radiation in utero will develop childhood leukemia
(background rate of 1/3000).

Although no documented adverse fetal effects have been reported with

MRIs, the National Radiologic Protection Board arbitrarily advises against
use in the first trimester.

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 - 42 -15342
Infectious Exposures During Pregnancy
Obstetrics, 3rd Ed., Gabbe et al.

Chlamydia, Gonorrhea, Trichomonas, Syphilis

SEE PAGES 21-22.

Chicken Pox
Women should use contraception for three months after Varivax (live-
attenuated vaccine).
Pregnant women, immune-compromised, or patients who have received
high-dose steroids within 30 days SHOULD NOT BE IMMUNIZED.

IF EXPOSED DURING PREGNANCY (95% of susceptible hosts will

aquire):
a. Verify positive exposure, if possible
b. DO NOT have the patient come to clinic or to L&D. There is a special
room in the ER where you can evaluate the patient
c. If there is time, check patient’s immunity (Varicella IgG)
d. IF SEROLOGY NEGATIVE (or serology cannot be obtained):
*** VZIG (125 units/10 kg; maximum of 625 units) WITHIN 96
HOURS.
*** No recommendation for termination.
e. Discuss s/sx of varicella encephalitis and pneumonia
f. If patient becomes systemically ill with Varicella:
*** IV Acyclovir 500 mg/m2 every 8 hours

First trimester: 0.4 % frequency of congenital infection

Second trimester congenital infection (2% incidence) can result in SAB,

IUFD, and “varicella embryopathy” [limbs, skin, CNS, eyes].Can isolate
virus in amniotic fluid and cord blood (IgG), yet it does not predict the
clinical course. Ultrasound is more helpful

Third trimester: if mother is infected 5 days BEFORE to 2 days AFTER

delivery, the baby is at risk for infection. Due to a 3% mortality, the infant
should receive VZIG if mother is infected around delivery

42
 - 43 -15343

Rubella

Women should use contraception for three months after immunization (live-
attenuated vaccine).
Pregnant women, immune-compromised, or patients who have received
high-dose steroids within 30 days SHOULD NOT BE IMMUNIZED.

Congenital infection causes: deafness (60-75%), eye defects (10-30%), CNS

defects (10-25%), and heart malformations (10-20%; PDA most common).
Only 25% of affected infants are later able to be enrolled in mainstream,
regular schools

If exposed within four weeks of conception, 50% of infants will show signs
of congenital infection. Five to eight weeks post-conception, 25% of infants
will be infected. Nine to twelve weeks post-conception, 10% will show signs
of infection.

CMV

 1% of infants born in US have congenital CMV.

 #1 cause of hearing defects in children.
 Highly contagious from blood, sexual contact, saliva, or urine.
 Exposures usually from small children and from sexual contacts (multiple
partners increases risk).
 1-4% of nonimmune pregnant women seroconvert during pregnancy after
exposure
 50% of the those fetuses will be infected
 5-18% of the infants will be symptomatic at birth. (Hepatosplenomegaly,
intracranial calcifications, jaundice, growth restriction, microcephaly,
chorioretinitis, hearing loss.)
 No vaccine available.

43
 - 44 -15344
Parvovirus
No vaccine available

IF EXPOSED:
1. Check patient’s immunity (IgG)
2. If not immune, check IgM in three weeks
3. If IgM positive, obtain serial ultrasounds

First trimester frequency of severely affected fetuses: 19%

Second trimester frequency of severely affected fetuses: 15%
Third trimester frequency of severely affected fetuses: 6%

Hepatitis A
Inactivated virus vaccine safe for
use in pregnancy.

If mother does not become severely ill, not a serious risk to fetus. However,
infants born to mothers who are incubating virus or are acutely ill at delivery
should receive one dose of 0.5 ml standard immune globulin.
Treat exposure within two weeks with standard immune globulin, 0.02 ml/kg
IM and give vaccination.

Hepatitis B
Inactivated virus vaccine safe for use in pregancy if high risk or exposed.

If no immunoprophylaxis, perinatal transmission to the neonate is 10-20% in

women who are HepBsAg positive. If she is HepBsAg and HepBeAg
positive, transmission increases to 90%. Infants born to positive mothers
should receive HepB Immunoglobulin (HBIG) 0.5 ml IM and start the
hepatitis vaccination series.

Exposed, nonimmune, mothers should receive HBIG 0.06ml/kg IM and start

the vaccination series.

44
 - 45 -15345
Hepatitis C

No vaccine.

75% of patients with hepatitis C are asymptomatic. The prevalence in a

general OB population is 1-3%.

Perinatal transmission 10-44%. Benefit of immunoprophylaxis for the

neonate has not been proven.
Interferon therapy may not be given in pregnancy.

Exposure should be treated with 0.06 ml/kg of standard immune globulin.

Rabies
Killed virus vaccine, when indicated.

Exposure treated with rabies immune globulin (half dose at injury site and
half in the deltoid), and vaccination.
100% fatal if not treated.

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 - 46 -15346
VACCINATIONS
(ACOG Technical Bulletin Number 160)

LIVE Vaccines: Measles, Mumps, Rubella, Polio, Yellow Fever

Tetanus and diphtheria toxoids (altered bacterial exotoxins) are the only
routine vaccinations recommended to be given in pregnancy.

Hepatitis B series should be given (even in pregnancy) to known non-

immune pts or those with risk factors, including:
3. IV drug use
4. Acute episode of ANY STD
5. Multiple sex partners
6. Work in a health care or public safety field
7. Household contact with hepatitis B carrier
8. Work or residence in an institution for the developmentally disabled
9. Work or treatment in a hemodialysis unit
10. Receipt of clotting factor concentrates for bleeding
disorder

Yellow Fever and primary Polio vaccines (three doses of the enhanced-
potency inactivated vaccine) should be given to pregnant women if traveling
to an area where the exposure risk is high.

MMR vaccine should be given to non-immune pts at least three months

before pregnancy (check rubella IgG only if not sure). Children who receive
the MMR do not transmit the illness to their pregnant mothers.

Varicella: women should use contraception for three months after

immunization with Varivax (live-attenuated vaccine). Pregnant women,
immune-compromised, or patients who have received high-dose steroids
within 30 days SHOULD NOT BE IMMUNIZED.

HPV: Not recommended in pregnancy.

46
 - 47 -15347
**Gardasil indicated in females aged 9-26, even if already exposed or
diseased, unless severely allergic to baker’s yeast. Given IM in 3-dose series
at 0,2,and 6 months.

47
 - 48 -15348

CLINIC SCHEDULE

Monday Tuesday Wednesday Friday

A R2 R1 ER
M UUMC R1 Nights
“Beeper R2 Nights
Doc” R3 Nights
R3 REI

P R2 LDS R2 OB UU R1 OB UU
M GYN R2 OB IMC R3 IHC Gyn
R3 DAY R2 Onc R3 Elective
FLOAT R1 Wards/MICU R1 IHC GYN
R3 ONC
R1 IMC/US

** In January only:
 R1 IMC/US will be Friday AM (there will be
nobody on ER that month)
 R1 Wards will be Wednesday PM
 R1 MICU will be Monday PM

48
 - 49 -15349
PRENATAL CLINIC CARE

Normal Prenatal Visits: q 4 weeks until 32, then q 2 until 36, then q 1

8-12 weeks/First visit

• Explain how clinic works – residents, students, attendings
• Give “New OB” packet
• Rx for Prenatal Vitamins
• Thorough Exam
• Prenatal labs:
1. Send to lab: “OB panel” = T&S, CBC, Rubella, VDRL, HepBsAg, HIV
2. Send CCUA and culture
3. Perform Pap and GC/CT
4. Depending on risk factors: sickle screen, glucose screen, PPD, baseline
24 hour urine for protein and creatinine)
• Diet:
1. Ask about hyperemesis – give Rx for Vit B-6, Unisom, Phenergan?
2. Add extra 300 kcal/d
3. Ca 1200mg/d
4. Folate 0.4mg/d (4 mg/d in high risk = AEDs or prior child with NTD
5. No unpasteurized dairy or raw meat
• Stop smoking, etoh, drugs
• Med review
• Discuss Exercise, Seatbelts, Domestic Violence, Depression, Finances
* Discuss use of E.D. for emergencies up to 20 wks
• No cat litter (toxo)
• Fetal growth, genetic dz prn: Tay-Sachs, Sickle Cell, Thalassemia, CF,
NTD,MCV’s in Asian pt’s.
• FHR by doppler usually at 12 weeks

** Dictate into PowerChart for emergency purposes

13-16 weeks
• MSAFP at 14-16. – for abnormal results call genetic counseling to set
up appt and u/s.
• Normal weight gain = ½ lb/wk in first and second trimester

49
 - 50 -15350

17-21 weeks
• screening ultrasound at 18-20 wks
• Ask about fetal movement – usually at 16-20 wks
• Discuss PP contraception
• Discuss use of OB Emergency Services (L&D) after 20 weeks, NOT
E.D.
22-28 weeks
• Labs = 1º GTT and repeat Hct at 28 wks  3º GTT if abnormal
• Hct if indicated
• Rhogam if indicated (300 mcg IM x1)
• Prenatal Classes/birth plan
• Third trimester sx: breast sx, swelling
29-32 weeks
• Breast vs bottle
• PTL, kick counts, s/sx labor
• Travel in 3rd trimester: have the name of an MD where you are going
and carry records (airline ok til 36 weeks)
• Leopolds
• Baby bag: robe, lotion, toiletries, CDs, etc

33-40 weeks
• GBS culture at 36 weeks. If PCN allergic then order sensitivities.
• S/Sx labor and PIH
• Leopolds, consider repeat U/S if breech (version at ~37+)
40+
• Biweekly NST/AFI

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 - 51 -15351

Red flags during history: STDs, renal diseases, cardiac disease,

collagen/rheumatic disorders, hepatic diseases, metabolic/endocrine
disorders, chronic UTIs, h/o preeclampsia, previous malformed or
macrosomic infant, previous stillborn, familial genetic disorders, recurrent
SABs, diabetes, substance abuse, epilepsy, and severe anemia.

Find a way to remind yourself and your nurse about routine tests on follow
up visits, Rhogam shots, and any special issues. Try post-it notes.

Be sure to check out your OB patients when you are on vacation to the
resident that will see them for their clinic appointments.

51
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Postpartum Visit

• NSVD = 6 weeks
LTCS = 2 weeks and 6 weeks

• Use pre-printed H&P form in clinic

• Ask about vaginal bleeding, sexual relations, birth control, interval

events, how mom and dad are coping, feeding, emotional support, and
how the family is adjusting to a new family member.

• 50% of postpartum women will have “blues” about two weeks after
Postpartum depression occurs in about 10%, and psychoses in 0.25%.

Treatment options include:

A. expectant management
B. medications
C. psychological counseling

• Breast exam and pap/pelvic

• If GDM  schedule 75 gram (two hour) glucola test at 6 week f/u

52
 - 53 -15353
AGE SPECIFIC SCREENING FOR WOMEN
from GUIDE TO CLINICAL PREVENTIVE SERVICES REPORT OF THE
USPS TASK FORCE 1996

AGE 11-24
• Height, weight, BP
• PAP when sexually active or 18yo, Q1 year until > 30 yrs
• Chlamydia screen (sexually active adolescents, prior STD,
new/multiple partners, clinical findings
• Rubella serology or vaccine history (Ok to offer vaccine without
serology if vaccine unavailable)
• Assess for problem drinking

AGE 25-64
• Height, weight, BP
• PAP, at least q3 yrs
• Cholesterol (periodic screening ages 45-65)
• Hemoccult stool age 50+ annually
• Sigmoidoscopy age 50+ q3-10 yrs
• Mammogram q1-2 yrs age 40-49, Q1 yr age 50-69, review risk/benefit
for age > 70
• Rubella serology or vaccine history (reproductive age)
• Assess for problem drinking

AGE 65 and OLDER

• Height, weight, BP
• PAP (interval based on RF)
• Hemoccult stool annually
• Sigmoidoscopy q3-10 yrs
• Mammogram q1-2 yrs to age 69, after based on assessment of benefit
• Assess for problem drinking
• Assess for hearing impairment

53
 - 54 -15354
Treatment of Non-STD Gynecologic Infections

Urinary Tract Infection

NONPREGNANT: Macrobid 200mg PO x 1 or…100mg BID x 7 d
Bactrim “DS” PO x 1 or… Bactrim BID x 7 d
Ciprofloxacin 250mg PO BID x 7 days
PREGNANT: Macrobid 100mg PO BID x 7 days

Cystitis = dyuria, frequency, U/A and culture with sensitivities

Nitrofurantoin
Bactrim

Bacterial Vaginosis = grey thin d/c, clue cells, (+) whiff , (+) nitrizine test

NONPREG: Metronidazole 500mg PO BID x 7 days

Cleocin cream (Clinesse) 2% daily PV qHS x 10 days
Metrogel 0.75% BID x 5 days
Metronidazole 2g PO x 1 (70% cure)
Clindamycin 300mg PO BID x 7 days
PREG (2nd/3rd): Metronidazole 250mg PO TID x 7 days OR 2g PO x 1
Clindamycin 300mg PO BID x 7 days
Metrogel 0.75% BID x 5 days (low-risk patients)

Yeast Vaginitis
* white discharge, pruritis (20% women no sx)
Fluconazole 150mg PO x 1
Ketoconazole 200mg PO BID x 5 days
Butoconazole 2% cream 5g PV x 3 days
Miconazole cream 2% x 7 days
Chronic: Vaginal cream x 14 days then Boric Acid (600mg BID 2x/wk)
Ketoconizole 100mg PO QD x 6 months (w/ serial LFTs)
PREG: Use only topical azole therapies x 7 days

54
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Treatment of Sexually Transmitted Diseases
The Medical Letter Handbook of Antimicrobial Therapy, 1996
ACOG Educational Bulletin No. 245, March 1998

Chlamydia
NONPREGNANT: Azithromycin 1 gram po x 1 dose
Doxycycline 100 mg PO bid x 7 days
Ofloxacin 300 mg po bid x 7 days
PREGNANT: Azithromycin 1 gram po x 1 dose

Gonorrhea
NONPREGNANT: Ceftriaxone 125 mg IM x 1 dose
Cefixime 400 mg PO x 1 dose
Ciprofloxacin 500 mg PO x 1 dose
Ofloxacin 400 mg PO x 1 dose
Bacteremia, arthritis, and disseminated:
Cetriaxone 1 gram IV qd x 7-10 days
or for 2-3 days followed by…
cefixime 400 mg PO bid or…
ciprofloxacin 500 mg PO bid to complete 7-10 days
PREGNANT: Ceftriaxone 125 mg IM x 1 dose
Cefixime 400 mg PO x 1 dose
If allergy to beta-lactams, then Spectinomycin 2 gr. IM x 1 dose

Trichomonas
PREGNANT and NONPREGNANT:
Metronidazole 2 g x 1 dose
350 or 500 mg bid x 7 days
Herpes (genital)
NONPREGNANT
First-episode Acyclovir 400 mg PO tid x 7-10 days
Recurrent outbreak Acyclovir 400 mg PO tid x 5 days
Suppressive Acyclovir 400 mg PO bid
PREGNANT
Severe, first-episode: Acyclovir 400 mg PO tid x 7-10 days

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 - 56 -15356
Syphilis

NONPREGNANT and PREGNANT (if pregnant and allergic to penicillin,

the US Public Health Service recommends hospitalization and
desensitization)
If pregnant, must be observed for 6-8 hours with first dose of penicillin. The
cytokine response (Jarisch-Herxheimer reaction) can cause fetal hypoxemia
and /or labor.

Early (primary, secondary, or latent less than one year):

Penicillin G 2.4 million U IM x 2 doses
Doxycycline 100 mg PO bid x 7days
Late (more than one year’s duration, cardiovascular, gumma, late-latent):
Penicillin G 2.4 million U IM q week x 3 doses
Doxycyline 100 mg PO bid x 14 days
Neurosyphilis:
Penicillin G 2-4 million U IV q 4 hours x 10-14 days
Penicillin G procaine 2.4 million U IM daily PLUS
Probenecid 500 mg qid PO BOTH x 10-14 days
Congenital:
Penicillin G 50,000U/kg IM or IV q 8-12 hours x 10-14 days
Penicillin G procaine 50,000 U/kg IM qd x 10-14 days

*** Follow RPR titer at 2-4-6-12-24 months after treatment.

HPV (genital)

To destroy visible lesion: careful application of 50-85%

TriChloroacetic Acid 50-80%
Podofilix 0.5% (not on cervix, vagina or during pregnancy)
Topical 5-FU 1-2% with weekly observation (not in pregnancy)
Excision, cryothrapy, or topical liquid nitrogen.

Vaginal delivery carries a risk of 0.04% for laryngeal papillomatosis in the

infant, not a high enough risk to recommend cesarean section. This is
thought to be caused by spread of HPV to the infant’s larynx.

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Treatment of Blood-Borne Sexually Transmitted Diseases

The Medical Letter Handbook of Antimicrobial Therapy, 1996

ACOG Educational Bulletin No. 245, March 1998
ACOG Technical Bulletin No. 193, June 1994

Hepatitis B
Exposed and nonimmune  HBIG .06ml/kg IM
Start the vaccination series
If a new diagnosis, obtain GI and infectious disease consults.
HepBsAg (+) without no prophylaxis  10-20% transmission
HepBsAg and HepBeAg (+)  90% transmission
Infants born to positive mothers  HepB IgG (HBIG) 0.5 ml IM
Start the vaccination series.

Hepatitis C
Exposed  0.6 ml/kg of standard immune globulin.
No vaccine available.
If a new diagnosis, obtain GI and infectious disease consults.
Prevalence in the general OB population is 1-3%.
In pregnancy, interferon cannot be used.
No evidence immunoprophylaxis is helpful to the neonate.

HIV
New diagnosis?  ID consult as the therapies/programs are dynamic.
Treating mother with AZT can decrease transmission from 28% to 8%.
In pregnancy, aggressive treatment is important.
-- may see patients on two nucleosides plus a protease inhibitor
No clear association between viral load and transmission.
Recent data seems to indicate C/S if untreated and/or high viral load.
If on HAART at delivery, they should continue HAART.
If not on HAART  AZT 2mg/kg load with a subsequent of 1 mg/kg/hour
Nevirapine 200 mg PO x 1

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Pelvic Inflammatory Disease

Diagnosis = All of the following:

1. abdominal tenderness
2. cervical motion tenderness
3. adnexal tenderness

Plus one/more of the following:

1. WBC>10,000
2. Temp>38.0 C
3. Intracellular gram negative cocci on SC-90 smear or CT positive
4. Pelvic abscess
5. Mucopurulent cervicitis/culdocentesis
6. Increased CRP/ESR

Hospitalize if: uncertain diagnosis, pre-pubertal child, surgical emergency

cannot be ruled out, pregnancy, severe illness, noncompliant patient, failed
outpatient therapy.

Consider laparoscopy if uncertain diagnosis and/or surgical emergency

cannot be ruled out. .If a TOA is suspected and the patient is stable, consider
IV antibiotics x 48 hours (in semi-Fowler’s position). If patient’s status/exam
worsens, then to take them to the OR

Inpatient: Cefoxitin (Mefoxin) IV OR Cefotetan (Cefotan) IV

PLUS
Doxy 100 mg IV q 12 hours OR Clinda 900 mg IV q 8 hours
PLUS
an aminogylcoside

Outpt: Ceftriaxone 125 mg IM x 1 dose

PLUS
Doxy 100 mg PO bid x 10-14d OR Ofloxacin 500 mg PO qd
PLUS
Metronidazole 500 mg PO bid x 7-10 days OR Clindamycin

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STD REPORTING -- Either fax available forms or call in:

Andrea Price – Surveillance Specialist, SLVHD

Phone: 534-4607
Cell: 554-2896
Fax: 534-4557

REPORT IMMEDIATELY:

 Anthrax 
 Botulism 
 Cholera 
 Diphtheria 
 Haemophilus influenzae (invasive disease) 
 Measles (Rubeola) 
 Meningococcal disease (invasive) 
 Pertussis 
 Plague 
 Poliomyelitis (paralytic) 
 Rabies (human and animal) 
 Rubella (including congenital syndrome) 
 Severe Acute Respiratory Syndrome (SARS) 
 Smallpox 
 Syphilis (all stages and congenital) 
 Tuberculosis 
 Tularemia 
 Typhoid (cases and carriers) 
 Viral hemorrhagic fever 
 Yellow Fever 
● Any sudden or extraordinary occurrence of infectious or communicable
disease (outbreak or suspected outbreak)

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REPORT WITHIN 3 WORKING DAYS:

 Acquired Immunodeficiency Syndrome (AIDS)

 Adverse event resulting after smallpox vaccination
 Amebiasis
 Arbovirus infection
 Brucellosis
 Campylobacteriosis
 Chancroid
 Chickenpox
 Chlamydia trachomatis
 Coccidioidomycosis
 Colorado tick fever
 Creutzfeldt-Jakob disease and other transmissible human spongiform
encephalopathies
 Cryptosporidiosis
 Cyclospora infections
 Dengue fever
 Echinococcosis
 Ehrlichiosis (human granulocytic, human monocytic, or unspecified)
 Encephalitis
 Enterococcal infection (vancomycin-resistant)*
 Enterohemorrhagic Escherichia coli (EHEC & O157:H7) infection
 Giardiasis
 Gonorrhea (sexually transmitted and ophthalmia neonatorum)
 Hansen disease (leprosy)
 Hantavirus infection and pulmonary syndrome
 Hemolytic-uremic syndrome (post-diarrheal)
 Hepatitis A
 Hepatitis B (cases and carriers)
 Hepatitis C (acute and chronic infection)
 Hepatitis (other viral)
 Human Immunodeficiency Virus (HIV) infection
 Influenza-associated hospitalization

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 Influenza-associated death if the individual was less than 18 years of age
 Legionellosis
 Listeriosis
 Lyme disease
 Malaria
 Meningitis (aseptic and bacterial-specify etiology)
 Mumps
 Norovirus (formerly called Norwalk-Like Virus) infection
 Pelvic inflammatory disease (PID)
 Psittacosis
 Q Fever
 Relapsing fever (tick-borne or louse-borne)
 Reye syndrome
 Rheumatic fever
 Rocky Mountain spotted fever
 Saint Louis encephalitis
 Salmonellosis
 Shigellosis
 Staphylococcal diseases (all outbreaks)
 Staphylococcus aureus with resistance or intermediate resistance to
vancomycin isolated from any site
 Staphylococcus aureus (MRSA) isolated from any site*
 Streptococcal disease (invasive or isolated from a normally sterile site)
 Streptococcus pneumoniae (drug-resistant or isolated from a normally
sterile site)
 Tetanus
 Toxic-Shock Syndrome (staphylococcal or streptococcal)
 Trichinosis
 West Nile virus infection

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 - 62 -15362
Counseling and Management of the Abnormal Pap

Screening begins: Begin within 3 yrs of coitus

No later than age 21
May delay if virginal and no hx sex abuse

Screening intervals:
q1 yr ages 21-30
q3 yrs if >30 with 3 neg screens or neg HR-HPV
test unless HIV, immunosuppressed, DES
exposed
q3 yrs if >30 with NEG high-risk HPV assay
stop if >65-70 with neg screens and no new risk
factor
continue yearly if hx of HGSIL
stop after benign TAH with no hx HGSIL

Order Gardasil for all pts. <27 who are at risk for HPV, even if they
have been exposed to one type of virus.
**Schedule is IM vaccines at 0, 2 and 6 months.

Cellular Differentiation:
Normal squamous epithelium
Squamous metaplasia = ASC-US  70-90% revert in 2-3yrs
Mild dysplasia LGSIL CIN-1  70+% revert in 1-2 yrs
Moderate dysplasia HGSIL CIN-2  50% revert in 1-2 yrs
Severe dysplasia HGSIL CIN-3  30% revert in 1-2 yrs
Carcinoma-in-situ HGSIL CIN-3
Invasive carcinoma

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 - 63 -15363

I. ASCUS  HPV DNA Testing (reflexive – don’t need to special order)

(-)  Repeat Pap in 3 months?
(+)  Colpo with ECC  if neg repeat in 12 months
OR…  Colpo if immunosuppressed.

II. ASC-H (ASCUS cannot exclude HGSIL)  COLPO

 up to 70% will have CIN-2 or CIN-3

III. AGUS  A. If Atypical Endometrial cells  EMB

B. If any other type  Colpo, ECC, EMB
(or… if 35 years or older or abnormal bleeding)

IV. LGSIL  Colpo & ECC -- OR -- Pap at 6&12 months

Do NOT LEEP!

V. HGSIL  Colpo & ECC

Colpo (-)  Repeat Pap q6 months until negative

Colpo (-) but HSIL  Repeat colpo
Colpo (+)  Treat with procedure (see below)

CIN I  Pap at 6 & 12 months, then yearly if both NL

CIN II  CRYO or LEEP

CIN III  LEEP

LEEP  Pap q 3-4 months until 3 consequetive NL

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 - 64 -15364
Emergent Vaginal Bleeding

Rule out PREGNANCY (SAB vs. ECTOPIC vs. MOLAR)

MASS
INFECTION
MENORRHAGIA….

DO NOT put a ring forcep through the cervix unless you are
ABSOLUTELY CERTAIN of gestational age, placentation, and
viability!

Vital signs
Abdominal exam  Peritoneal sx? Uterine tenderness?
Pelvic exam  Lacerations/lesions? How much bleeding?
Parts in os? Internal os open/closed?
Labs: GC/CT
Hematocrit
Rh type and if indicated, coags
** urine hCG **

A/P:

IF (-) hCG and NOT bleeding from a cervical lesion:

If severely anemic, may need to:

Admitfor observation and transfusion
Premarin 25 mg IV q 6 hours

If stable: OrthoCyclen (any monophasic)

3 pills for 3 days, 2 pills for 2 days, then finishing the pack
She will probably need an anti-emetic with that much estrogen.
Arrange F/U visit to asses her bleeding and do EMB if indicated.

Remember: No estrogen to smokers older than 35

Women prone to DVTs
Hepatic comprosised/failure patients

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Missed / Incomplete Abortions

IF (+) hCG and stable  consider a pelvic ultrasound

Incomplete SABs >14 weeks  can not be handled by D&C in the E.R.

Incomplete SAB < 14 weeks  suction D&C in the ER with an OB

attending.
Premedicate with Doxycycline 100 mg IV.
For pain, use: IV Versed (2-4 mg)
IV Fentanyl (50-100 mcg)
Paracervical block
** Give discharge instructions before you administer IV sedation.

Discharge meds: Doxycycline 100 mg PO BID x 7 days

(~42% decreased risk of infection)
Ibuprofen
Percocet

DAYS by LMP Β-Hcg Seen on TVUS

34.8 ± 2.2 914 ± 106 5mm Sac

5 weeks
40.3 ± 3.4 3783 ± 687 5mm Pole +/- FHR
6 weeks
46.9 ± 6.0 13178 ± 2898 Cardiac Activity
7 weeks

 80% of Abs occur in 1st tri &50% have chromosomal abnormalities

 20-25% of women have 1st/2nd trimester VB  ½ will abort

Medical Management (of 1st Tri SAB):

 Cytotec 800mcg PV (or 600mcg buccal)
 Repeat dose on Day 3 if incomplete by US
 D&C if incomplete by Day 8

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Ectopic Pregnancy

For most of our patients with ectopic pregnancies, we go to the OR,

however, could be given Methotrexate (ACOG Criteria, 1998):

Absolute Indications:
 Patient is HMD stable without active bleeding or sign of
hemoperitoneum
 Diagnosis is nonlaparoscopic
 Patient desires future fertility
 General anesthesia poses a significant risk
 Pat is able to return for follow-up care
 Patient has no contraindication to MTX;
(check LFTS, creatinine, and CBC with diff)
Relative Indications:
 Unruptured mass is 3.5cm or less at its greatest dimension
 No fetal cardiac motion is detected
 Pt’s hCG is < 6000-15,000 mIU/mL

Absolute Contraindications:
Breastfeeding Warn patient about:
Immunodeficiency Mucositis
Liver disease Signs of infection
Alcoholism ↑pain a few days after dose.
Blood dyscrasias
Allergy
Active pulmonary disease
Peptic ulcer disease
SINGLE-DOSE REGIMEN  Methotrexate 50 mg/m2 IM

 Check quant hCGs on Day 4 & 7 – need a 15% decline between

 IF sufficient, get weekly quants until undetectable or plateaus
 IF insufficient, repeat dose, repeat same follow-up or go to OR

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Molar Gestation

Evacuation (20% recurrence) vs. hysterectomy (2-3% recurrence)

Check LFTs, CXR, quantitative hCG (send as a tumor marker), and pelvic
exam.

Weekly hCGs until remission; if increase or plateau, then need a

metastatic work-up.

GTD (Gestational Trophoblastic Disease)

1. Nonmetastatic

2. Metastatic

a. Good Prognosis: last pregnancy < 4 months, hCG<40,000

mIU/mL, no brain or liver mets., no chemotherapy

b.Poor Prognosis: last pregnancy >4 months, hCG>40,000

mIU/dl, positive brain or liver mets., previous therapy, term
pregnancy

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Non-Emergent Vaginal Bleeding

Evaluation

Exactly how often and how long is she bleeding?

When did she start bleeding heavily?
Is the bleeding REGULAR (dates) or IRREGULAR?
Other health issues? Obese? Diabetic?
Anemia? Fainting or syncope? Missed school or work?
Recent health changes or new medicines?
Any post coital bleeding? Any dyspareunia? New partners? Anormal
discharge?
Using hormones now or ever?
Give patient menstrual chart to plot bleeding – charts in clinic 4.

Rule out PREGNANCY, MASS, and INFECTION….

Urine hCG.
Pap/pelvic/GC/CT/EMB  if lesion is visible, take a biopsy!
ECC = if high risk or greater than 35 years
Hematocrit, vital signs, laceration/lesions,

Consider a hormonal trial, perhaps with Ibuprofen, BUT no estrogen to:

-- smokers older than 35
-- pts with DVT risks
-- pts with hepatic compromise/failure

If that fails, consider:

office hysteroscopy (polyp or submucosal myoma)
diagnostic hysterscopy/D&C
pelvic ultrasound.

If all criteria met, therapy failed and not desiring fertility  HYST!

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ACOG Criteria for Hysterectomy for Abnormal Uterine Bleeding
(ACOG, 1994)

Confirmation of abnormal uterine bleeding

1. Hx of excessive bleeding : (a) profuse bleeding with flooding or clots

or repetitive periods lasting for more then eight days, or (b) anemia due
to acute or chronic blood loss
2. Failure to find UTERINE or CERVICAL pathology that would cause
bleeding
3. Lab data: (a) no endometrial neoplasia and (b) no cervical malignancy
4. No finding of remedial cause by D&C, hysteroscopy or hysterogram

Actions prior to procedure

1. Consider pt.’s medical and psychologic risks

2. Hormone therapy unsuccessful
3. No h/o bleeding diathesis or meds which would cause bleeding
4. R/o pregnancy
5. Assess ovulatory status by premenstrual EMB
6. Assess surgical risk from anemia and need for treatment
7. R/o cancer of the cervix and endometrium

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ACOG Criteria for Hysterectomy for Leiomyomas (ACOG 1994)

Confirmation of leiomyomas

1. Asymptomatic leiomyomas of such size they are palpable abdominally

and are a concern to the patient
2. Excessive uterine bleeding evidenced by either of the following: (a)
profuse bleeding with flooding or clots or repetitive periods lasting
more than eight days, (b) anemia due to acute or chronic blood loss
3. Pelvic discomfort caused by myomas: (a) acute and severe, (b) chronic
lower abdominal or low back pressure, (c) bladder pressure with
urinary frequency not due to urinary tract infection

Actions prior to procedure

1. Confirm the absence of cervical malignancy

2. Eliminate anovulation and other causes of abnormal bleeding
3. Confirm the absence of endometrial malignancy if abnormal bleeding
present
4. Assess the surgical risk from anemia and the need for treatment
5. Consider patient’s medical and psychologic risks concerning
hysterectomy

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URINARY INCONTINENCE

QUALITY
Stress….leak with cough, sneeze, laugh?
Urge…..leak when you hear running water, come home from the store
with the bag of groceries and leak when the key hits the keyhole?
(Can be a combination)

FREQUENCY
Do you leak once a month, a week, a day?

QUANTITY
A few drops? Soak through a pad? Run down your legs?

MORE INFO....
Neuro symptoms? (toes/S5) Back surgery? Other surgeries? Incontinence
of stool? Leak with orgasm or intercourse? (Leak with orgasm is detrusor
instability, like urge incontinence; leak with penetration is stress
incontinence) Empty all the way? Dribble/generate a good stream?
Frequency or urgency? How many times are you up at night to void? (in
elder, normal is less than or equal to two times) Bed wetting?
Medications? Have you ever tried a pessary or continence device in the
past? Need to splint (with the fingers in the vagina) to defecate or void?
Anything bulging from the vagina?

WHAT IS THE NUMBER ONE PROBLEM TO THE PATIENT?

EXAMINE THE PATIENT WITH AN ATTENDING

Supine pelvic with bivalve speculum, then take the speculum apart and
use one blade. If you have the patient bear down, be careful!

Standing exam (Dr. Norton) with one of the patient’s legs up on a step
(and CHUX on the floor).

Standing cough- need at least 150 cc in the bladder, turn the water on,
have patient jump, etc…

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Bladder Trials:

UROGYN  300 ml NS into bladder

Remove foley and void
If > 150 retained, send out with self-cath until f/u
(up to 2 weeks)
Or re-foley and send out and try again in 2-3 days

Always send home with propylaxisis  Macrobid 100mg PO daily

Normal PVR: young < 30-50 cc

eldery < 100 cc

Bladder diary:
Normal 24 hr. total= 40-50 ounces, or 1300-1500 cc
Normal void=250-300cc (7-10 oz.) at mid-day, am void=400-500 cc

HOW TO HELP
Stress meds (increase urethral tone): alpha agonists- Ornade, Entex LA,
Sudafed,
Stress devices: Hodge pessary, occlusive plugs
Kegel exercises: 50/day!
Electrical stimulation
Surgery

Urge meds:
Oxybutynin 2.5-5 mg tid
Ditropan XL 5, 10, or 15 mg QD
Detrol 1-2 mg bid

NOTE:
 The delivery system in Ditropan XL and Detrol is a capsule/gel which
is NOT digested.
 In eldery, may not want meds due to side-effects.
 Timed voiding can be helpful.

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PELVIC RELAXATION

Stages of Prolapse

Stage One: not normal, yet more than one cm above hymen

Stage Two: within one cm of hymen

Stage Three: greater then one cm from hymen

Stage Four: complete eversion (“inside-out”)

ACOG Criteria for Hysterectomy for Pelvic Relaxation (ACOG

1994)

Confirmation of indication
1. Spontaneous, symptomatic protrusion of the cervix or vagina and
contiguous organs to or through the introitus when standing or
straining
2. Interferes with the patient’s quality of life

Actions prior to procedure

1. Document patient’s symptoms and physical findings
2. Document absence of cervical pathology
3. Evaluate abnormal uterine bleeding, if present
4. Document patient’s agreement to sterilization
5. Consider patient’s medical and psychologic risks considering
hysterectomy
6. Administer prophylactic antibiotics prior to vaginal procedure for
women of reproductive age
7. Evaluate stress incontinence if present

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 - 75 -15375
PELVIC PAIN

Rule out PREGNANCY, MASS, and INFECTION.

Place. Can you point with one finger where it hurts the most?

Provocative. What makes the pain worse?

Palliation. What makes the pain go away or decrease?

Quality. Sharp, dull, burning, stabbing, grabbing, cramping?

Radiation. Does the pain travel anywhere else?

Sensory. Any numbness, tingling, or associated feelings?

Timing. How long have you had the pain? How long does it last? Does it
come and go? Is it associated with menstrual cycles?

Focus the exam to rule out GI, urinary, and musculoskeletal causes of
pain. Also observe skin lesions, examine the abdomen while the patient is
flexing the rectus muscles, Q-Tip to isolate pain on perineum and vaginal
mucosa, check levator tenderness, isolating pain at the vestibule, defining
if there is pain with pressure on the perineal body.

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ACOG Criteria for LAPAROSCOPY for Pelvic Pain
(per HT Sharp, MD)

1. Pain greater than three months

2. GI/GU/musculoskeletal work-up negative
3. Trial of NSAIDS/hormonal therapy

ACOG Criteria for Hysterectomy for Pelvic Pain (ACOG 1994)

Confirmation of indication

1. No remediable pathology found on laparoscopic exam

2. Presence of pain for more than six months with a negative effect on the
patient’s quality of life

Actions prior to procedure

1. Document failure of OCPs, NSAIDS, and/or induced amenorrhea

2. Evaluate GI, GU, Musculoskeletal systems for possible sources of pain
3. Evaluate pt’s psychologic and psychosexual status for a somatic cause
4. Confirm the absence of cervical pathology

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VULVODYNIA

Dermatitis (usually burning with placement of ointments or touch)

• Hypoestrogen
• Irritant/contact
• Allergic
• Infectious

Cyclic Candidiasis

Vulvar Papillomatosis

Dysethetic Vulvodynia (constant)

• Neurontin 100 mg tid

-- increase slowly to goal of 1200 mg/day.
-- taper after 3-6 months
• Amitriptyline 25mg bid

Pudendal Neuralgia (burning/shooting pain- occasionally in rectal area)

• GI/GU cancer?  pelvic MRI

Vulvar Vestibulitis (adjacent tissures could have an aberrant nerve fiber)

1. Crisco
2. 1% hydrocortisone
3. Topicort
4. Estrogen cream

• Surgery is 90% corrective

• Estrace can be helpful if postpartum or on Depo.

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ENDOMETRIOSIS

ACOG Criteria for Hysterectomy for Endometriosis (ACOG, 1994)

Confirmation of indication (presence of 1 and 2, or 1 and 4)

1. Prior detailed description or histologic diagnosis of endometriosis
2. Failure of conservative measures to control significant symptoms
3. Presence of persistent, significant pelvic mass
4. Significant involvement of other organ systems, such as ureteral or
intestinal obstruction
Actions prior to procedure
1. Attempt medical or conservative surgical therapeutic trial or document
involvement of other organ systems.
2. Confirm by cytologic study the absence of cervical malignancy
3. If abnormal bleeding, obtained endometrial sample or perform D&C
4. Consider pt.’s medical and psychologic risks concerning hysterectomy
5. Document discussion of implications regarding ovarian function,
ovarian involvement in the disease, castration and probability of
recurrence

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INFERTILITY – The Clinic 4 Work-Up

Definition: no pregnancy after one year of unprotected intercourse.

History of BOTH PARTNERS, including:

OB and detailed GYN histories, medical history, surgical history,
exposures, occupation, previous children, h/o eating disorder,
current/past medications, STDs, PID, endometriosis, previous work-
up/evaluation/meds, retrograde ejaculation, postpubertal mumps,
hypospadias, h/o chemotherapy, septic AB, obstetrical trauma.

Exam: attend to habitus, skin, external genitalia and bimanual exam.

Labs: GC, CT, finger stick glucose, TSH

1. Does she ovulate? The history can be helpful in telling you

whether she is ovulating, yet, a BBT chart (three months) is an
inexpensive way to confirm ovulation.
a) Urine LH (“ClearVue” at Costco or Walmart)
b) Serum progesterone at mid-luteal phase
c) Basal body temperatures / Track PMS symptoms\

2. Is his sperm normal? A semen analysis ($125 for good

comprehensive work-up) is also a good place to start. Clinic 5
does the analysis; forms are in the REI box in the back room of
Clinic 4.

3. Is her reproductive tract normal? A hysterosalpingogram one

week after her menses can document tubal patency and normal
intrauterine cavity.

4. Hamster Egg “Penetration” Assay

5. Liberal basal hormone testing

6. Pelvic Ultrasound

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If she is not ovulating, consider and ovulation inducing agent.

Rx: Provera (Medroxyprogesterone Acetate) 10 mg PO daily x 5

days.
This should induce an episode of bleeding after discontinuation.
(If she is not making estrogen [premature ovarian failure] she obviously
would not have a bleeding episode.)

Day #1 = The first day of bleeding.

Day #5 = Begin Clomid 50 mg po qd x 5 days.
Day #10 = Intercourse every other day for seven days.

Clomid causes ovulation in about 70% of patients.

Pregnancy rate of 40% and twin risk is 5-10%.
Max of 6 cycles.

If the semen analysis is abnormal, get an REI and possibly Urology

consult.

Normal analysis:
Volume > 2ml
Count > 40,000,000
Motility > 50%
normal morphology > 60%
pH = 7.2-7.8

If you need to do more than Clomid, discuss/manage the case with one of
the REI faculty.

Consider: hysteroscopies, inseminations, GIFT,

IVF can get expensive. Get some experienced help.

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DEPRESSION: MDD, Pregnancy, and Postpartum depression

Criteria for Major Depressive Episode (Amer Psych Assoc, DSM4, 1994)
Five or more present during a 2-wk period, including #1 and #2:
1. Depressed mood most of the day
2. Marked ahedonia
3. Significant weight loss/gain
4. Sleep disturbance
5. Psychomotor agitation or retardation
6. Fatigue
7. Feelings of worthlessness or excessive guilt
8. Diminished ability to think/concentrate
9. Recurrent thoughts of death or suicide

 7-13% of pregnant women experience significant depressive symptoms

 70% with hx of MDD who have stopped meds report 1st trimester
recurrence

Fluoxetine (Prozac) -- most widely studied, found to be safe in all

trimesters.
 Studies are beginning to show same for newer SSRIs
 Reports of fetal withdrawal prompt some MDs to taper before delivery
 Should be restarted at therapeutic dose after delivery

Paroxitine (Paxil) -- FDA reported that when taken in the first 3 months
of pregnancy, may increase risk of fetal heart defects.

TCAs can be used and do not d/c if necessary for maternal safety.
 Nortryptiline and Desipramine are preferred for less anticholingeric
orthostatic hypotension
 Category C = Amitriptyline and Clomipramine
 “Safety Unknown” = Nortriptyline, Imipramine, and Desipramine

Benzodiazepines – Category D, avoid for potential fetal benzo syndrome

 Conflicting reports of teratogenicity
 Risk/benefit ratio does not justify use in pregnancy

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Postpartum Depression:
 “Blues” usually self-limited and supportive care adequate
 13% may need intervention – if sx occur beyond 2 weeks
 Rx proven effective = Sertraline (Zoloft), Venlafaxine
(Effexor), and Fluoxetine (Prozac)

Postpartum Psychosis:
 1-2 per 1000 births
 Infanticide 0.6-2.5 per 100,000 births
 Consider PTSD in differential

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Emergency Contraception
From lecture by Jennifer Trauscht-Van Horn, MD

* Works primarily by suppressing or delaying ovulation.

Of 1000 women who have intercourse at midcycle:

80 pregnant with no birth control
20 pregnant with estrogen/progestrone EMERGENCY contraceptive
pill
10 pregnant with progesterone-only EMERGENCY contraceptive
pill
1 pregnant with IUD insertion within 5 days

Estrogen and progesterone: (q 12 hrs. x 2 doses)

Preven * no longer marketed

Ovral 2+2 (white pills)
LoOvral 4+4 (white pills)
Alesse 5+5 (pink pills)
Levlite
Trilevlen
Triphasil
Nordette

*** Prescribe anti-emetic with combined OCP management!

(20 % emesis, 50% nausea)
Have pt take an hour before the first dose.
If vomit < 30 min after taking, or see pills, must re-take them.

Progesterone:

Plan B = 1 pill q12 hr x 2 doses

Ovrette= 20 pills q 12 hr x 2 doses

*** Not carried in all pharmacies, but can give Rx ahead of time!

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Preoperative Visit

 Before you can schedule a case, you need to ask an

attending to staff the case (usually the clinic attending or
the GYN attending who will be on service on the date the
case is scheduled).
 THE GYN CHIEF MUST BE MADE AWARE OF THE
CASE!!!
 And check with your team to see if your absence is OK.

There used tobe a preoperative packet in clinic which had several

forms/order sheets which needed to be filled out – now you just need to
ask an upper level resident what all needs to be done to authorize the
procedure. For Medicaid patients you need a documented normal pap
smear within one year, a negative BHCG and written consent.

Obviously, your dictated “OB/GYN Clinic H&P” should be focused to

the problem and describe the risks, benefits, alternatives discussed with
the patinet at time of consent.

Any concerns should be addressed, documented, and evaluated well

before the surgery.
 Sterilization should have a normal pap documented.
 ASCVD, heart murmurs, COPD, or asthma might need
cardiology and/or pulmonary preoperative evaluations.
 Endocrine diseases like diabetes and hypothyroidism should be
evaluated.
 Elderly patients should be asked about their functional status
and special issues addressed.
 Status of psychiatric illnesses should be documented.

*** For pre-op anesthesia evaluation, call clinic 1B.

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CONSENTS
Cesarean Section
Risks include hemorrhage, infection, damage to surrounding
organs/tissues including but not limited to uterus, tubes, ovaries, ureters,
bladder, bowel, vessels, and nerves. Risks of transfusion, if necessary,
include (see below).

TOL/VBAC counseling and deliveries

Risks of include 1% rupture with prior LTCS and 20% chance of major
fetal or maternal morbidity.

 2-3% rupture risk with unknown uterine scar

 10% rupture risk with known classical scar (requiring repeat C/S)

 Success depends on prior C/S indication:

o 75-86% success after nonrecurring indications for previous
C/S
o 50-80% success after recurring indications (dystocias)
o 67-73% success if previous dystocia C/S done at 5-9cm
o 13% success if performed after complete

 CANNOT use high-dose pitocin, but can induce/augment:

o 80% success with spontaneous onset of labor
o 68% success with pitocin augmentation

 Internal monitors early if there is any concern.

 Epidurals rarely mask the signs/sx of uterine rupture.

 Continuous EFM.

 No Jacuzzi.

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Transfusion (risks per million) :
Risks include :
HIV ~1
Hep C ~1
Hep B ~4
Allergy ~ 1-4
Transfusion-related lung injury ~ 125

* If the pt refuses transfusion, they must sign refusal papers

* from Goodnough LT. Risks of blood transfusion. Crit Care Med
2003;31 (suppl):S678-86.

Bilateral Tubal Ligation

Risks include hemorrhage, infection, damage to surrounding
organs/tissues including but not limited to uterus, tubes, ovaries, ureters,
bladder, bowel, vessels, and nerves. Failure occurs 4-5/1000. There is an
increased risk that if pregnancy occurs, it will be ectopic.

Discuss:
 This procedure is considered permanent and reversal is available but
very expensive (cash) and only 50% effective.
 30% of women under 30 years old regret sterilization.
 Younger patients have more time for method to fail.
 “CREST” Study showed overall 1.85% failure rate for all methods.
-- postpartum partial salpingectomy was lowest at 0.75%
-- laproscopic spring clips had highest at 3.65%
-- Filshie clips compare favorably in 5-yr studies so far

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WARDS

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Shortness of breath

Causes
1. Pulmonary embolus
2. CHF : hypervolemia, myocardial infarction, acute renal failure
3. Bronchospasm
4. Pneumonia
5. Bronchial plugging
6. COPD exacerbation
7. Anaphylaxis

History
1. Acute or subacute
2. Concurrent chest pain or pleuritic component
3. Cardiac and pulmonary history
4. Tobacco use
5. Medications
6. Oxygen in hospital or at home
7. Level of activity at start of dyspnea

PE
1. General: comfort, diaphoresis, ability to talk
2. Neck: JVD
3. Chest: crackles, stridor, wheezes, diminished sounds
4. Heart: rate, rhythm, murmurs
5. Extremities: edema, cyanosis

Labs
1. ABG
2. CXR, EKG
3. If indicated, consider spiral CT, V/Q with dopplers, or pulmonary
angiogram

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Chest Pain

Causes
1. Chest wall: fracture, costochrondritis
2.Cardiac: MI, angina, pericarditis,
endocarditis, arrhythmia
3. Pulmonary: PE. Pneumonia
4. Esophageal: inflammation, spasm
5. Aorta: dissection
6. Abdominal (subdiaphragm): abscess,
CO2, cholecystitis, pancreatitis, gastritis
7. Musculoskeletal: DJD, Zoster, strain

History
1. Dyspnea
2. PPQRST
3. Cardiac and pulmonary history
4. Medications
5. Level of activity at start of dyspnea

PE
1. Vital signs/stability
2. General: comfort, diaphoresis, ability to talk
3. Neck: JVD
4. Chest wall tenderness
5. Pumonary: crackles, stridor, wheezes, diminished sounds
6. Heart: rate, rhythm, murmurs
7. Abdomen: TTP, mass, peritoneal sx
8. Extremities: edema, cyanosis

Labs
1. EKG
2. ABG
3. Cardiac enzymes
4. PCXR

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Confusion

Causes
1. Hypoxemia
2. Fever
3. Metabolic derangements (hypoglycemia, hypercalcemia, uremia,
hepatic coma)
4. Internal hemorrhage (leading to hypoxemia)
5. Infection/sepsis
6. Medications
7. CNS problem (post-ictal, meningitis, CVA)
8. Dementia

History
1. Acute or subacute
2. Medications
3. Oxygen in hospital or at home
4. Underlying conditions

PE
1. Vital sign
2. Neurologic exam
3. General: comfort, diaphoresis, ability to talk
4. Chest: crackles, stridor, wheezes, diminished sounds
5. Heart: rate, rhythm, murmurs
6. Abdomen: TTP, mass, peritoneal sx
7. Extremities: edema, cyanosis

Labs
1. ABG
2. CXR,
3. EKG
4. Electrolytes
5. Panculture-including CSF if neurologic exam is abnormal
(Head CT before spinal tap)

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Fever
Two oral temperatures 38.0 six hours apart or one temperature of 39.0.

Causes
1. Postoperative atelectasis and cytokine response (usually within first 48
hours).
2. Aggressive Strep A infections can also occur within the first 48 hours
post-op. Obviously, examine the patient!
3. Wound infection (usually polymicrobial)
4. UTI
5. Pneumonia
6. Endomyometritis (if VD, think retained POC)
7. Septic Pelvic Thrombophlebitis (ladder-like temperature curve, no
response to antibiotics)
8. Drug fever
9. Abscess
10. If ascites, spontaneous bacterial peritonitis

PE
1. Vital signs
2. Chest: crackles, diminished sounds
3. Heart: rate, rhythm, murmurs
4. Abdomen: TTP, mass, peritoneal sx

Management
1. CBC with diff
2. If diabetic, hypoxemic, or unstable, obtain BMP and ABGs
3. CXR
4. Urine, blood, and, if indicated, wound culture. (Piece of tissue is
superior for wound culture)
5. O2 and IVF
6. Antibiotics after cultures sent

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ELECTROLYTE IMBALANCES

HYPOKALEMIA

Causes:
Inadequate intake, vomiting, diarrhea, Golytely prep,fistula,diuretics,
gentamicin,amphotericin,Cushing’sSyndrome, hyperaldosteronism,
Barter’ Syndrome, Liddle’s Syndrome, RTA, metabolic alkolosis, acute
hyperventilation

Effects: weakness, paralysis,lethargy, constipation

** DO NOT SUPPLEMENT RENAL FAILURE PATIENTS.

** KNOW THE CREATININE BEFORE YOU SUPPLEMENT.

KCl sliding scale if creatinine <1.3:

Serum K Meq KCI to give PO/IV

3.8-3.9 20
3.6-3.7 40
3.4-.35 60
3.2-3.3 80
3.0-3.1 100
2.5-2.9 100-150
2.0-2.4 150-200

Potassium can be given as:

40 mEq PO q 4 hours – OR – IV over 4 hrs
10 mEq IV over one hour by peripheral line
20 mEq IV over one hour by central line.

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HYPERKALEMIA

Causes: iatrogenic, ATN, myonecrosis

Get an EKG!:

K >6.5  Narrow, peaked T waves (usually in V3 and V4)

K 8-9  QRS widens and p waves flatten or are lost
K >9  Idioventricular escape rhythm

Treatment and Noticeable Effects:

• 10 min  Ca Gluconate 1 gram
(stabilizes the cardiac cell membranes)
• 30 min  1 amp D50 with 10 units of regular insulin IV
(drives potassium into the cells)

1-2 hrs  Check Calcium and Potassium q 1-2 hours.

• Kayexalate has effect in 6-8 hours, yet you never use in patients with
renal failure.
• has an effect in 30 minutes.
• Sodium Bicarbonate has an effect in 30 minutes.
•
• Dialysis is another option.

Phosphorus Replacement

1. 72 mg PO4/5 cc PO TID or BID

2. 2 cc KPO4 solution IV over 4 hours x 3-4 doses

Magnesium Replacement

1. Mag. gluconate 500 mg PO BID

2. Mag. oxide 250-500 mg PO BID or QID
3. Mag. sulfate 2 cc of 50% sol IV= 1g (acidosis can result if used too
long)

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INSULIN DRIP (This is a conservative MICU protocol)

IVF BLOOD SUGAR REGULAR INSULIN

NS <70 1 AMP D50
NS 71-120 NOTHING
NS 121-150 1 UNIT
NS 151-200 2 UNITS
NS 201-250 4 UNITS
NS 251-300 6 UNITS
NS 301-350 8 UNITS
NS >350 10 UNITS CALL H.O.

SLIDING SCALE Insulin (Moderate)

BLOOD SUGAR REGULAR INSULIN

60-110 NOTHING
111-150 1 unit
151-200 2 units
201-250 3 units
251-300 5 units
301-250 7 units
>350 Redraw, if still high
give 8 units, call H.O.

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AGGRESSIVE HEPARIN PROTOCOL

1. Standard heparin concentration is: 25,000 units heparin in 500 cc

D5W=50 units/cc. Therefore, all incremental changes will be
multiples of 50 units/cc since there is no decimal option on the
IVAC pumps.
2. Initial heparin bolus 5000 units or as ordered.
3. Starting heparin infusion dose:
< 59 kg (< 130 pounds) = 800 units/hour
60-90 kg (131-199 pounds) = 1000 units/hour
>90 kg (>200 pounds) =1200 units/hour
4. Adjustment nomogram:

PTT (seconds) Heparin dose (change)

<60 Bolus by 3000 units and increase by
200 u/hr
60-75 Increase by 100 u/hr
76-100 NO CHANGE
101-120 Hold for 30 minutes, then decrease
by 100 u/hr
>120 Hold for one hour, then decrease by
200 u/hr

5. Obtain a PTT: 6 hours after every change

then q 6 hrs.x 12 hrs
then q day.

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CONSERVATIVE HEPARIN PROTOCOL

1. Standard heparin concentration is: 25,000 units heparin in 500

cc D5W=50 units/cc. Therefore, all incremental changes will
be multiples of 50 units/cc since there is no decimal option on
the IVAC pumps.
2. Initial heparin bolus 5000 units or as ordered.
3. Starting heparin infusion dose:
< 59 kg (< 130 pounds) = 800 units/hour
60-90 kg (131-199 pounds) = 1000 units/hour
4. Adjustment nomogram:

PTT (seconds Heparin dose (change)

<40 Bolus by 3000 units and increase
by 100 u/hr
40-49 Increase by 50 u/hr
50-75 NO CHANGE
76-85 Decrease by 50 u/hr
86-100 Hold for 30 minutes, then decrease
by 100 u/hr
101-150 Hold for one hour, then decrease
by 150 u/hr
>150 Hold for one hour, then decrease
by 300 u/hr

5 Obtain a PTT 6 hours after every change, then q 6 hrs. x 12 hrs.,

then q day.
6 If PTT obtained within 12 hours of starting thrombolytic therapy, do
not discontinue or decrease infusion unless active bleeding or
PTT>150 seconds.

To reverse heparin:

For every 100 units heparin = protamine 1 mg

For every 1 mg of LMWH = protamine 1 mg

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MISC. MICU TIDBITS
From lectures by Hildegard Smith, MD

Ventilator Weaning Parameters

Vc=10-15 cc/kg (>800cc)

MIF= accept-30 (normals: male 100-130, female 60-100)
RR<40 (normal 12-20)
Tv>500cc

IF RR/Tv(liters)<100, then 80% extubation success

Remember these are one time measures, and do not account for stamina.

PRESSORS Receptor Dosage Onset(durat.)

Profile (Tradition/Lit) (min)
Dopamine Alpha+beta 2-20 mcg/min 2-4(<10)

Dobutamine Beta>>alpha 2-20 mcg/kg/min 1-2(1-3)

(4-6) no greater
than 6
Norepinephrine Alpha>beta 2-20 mcg/kg/min Rapid (1-2)
(levophed) Blood to the (0.7-140)
head and heart
Epinephrine Alpha=beta 2-20 mcg/kg/min Rapid (1-2)
(+/- calcium) (2.8-70)

Phenylephrine Alpha 10-50 mcg/min Rapid (20)

(neosynephrin) NO BETA (10-70)

Isoproterenol Beta 2-20 mcg/min Rapid (8-50)

(isuprel) NO ALPHA Dose depend.

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DICTATING!

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DICTATION GUIDELINES – (Robert Silver MD -- 2/6/03)

1. Discharging resident dictates D/C summary.

2. DO NOT REQUIRE D/C summary if:

b. Received their antepartum care at the UUMC or one of its

affiliated clinics and had uncomplicated NSVD, VBAC, VAVD
or LFAVD between 37 & 42 weeks
c. BTLs after term NSVDs (if inpatient < 48 hours) – If greater
than 48 hours, D/C summary is required. Operative note required
either way.
d. Antepartum patients evaluated in the intake rooms for preterm
labor or other complications, but who are not admitted to L&D
or 2N, do not require a dictation (regardless of time spent in the
intake area).
e. Less than 48 hours hospital stays including short stays (ex. SAB
less than 14 weeks, antepartum, or GYN).

3. DO REQUIRE D/C summaries:

b. Antepartum admissions to either L&D or 2N > 48 hours.

c. Patients who have been transferred or referred from an outside
physician or facility (including uncomplicated normal vaginal
delivery at term, even if less than 48 hours).
d. All women who deliver at less than 37 weeks, but greater than
14 weeks, gestation require a discharge summary dictation,
regardless of route of delivery.
e. All patients who have a complication of pregnancy, including:
1. Any delivery method requiring dictation, including scheduled
LTCS, RLTCS, emergent C/S, classical C/S, forceps,
vacuum
2. 4th degree laceration or episiotomy extension
3. Complications requiring blood transfusion
4. Fetal stillbirth or intrapartum intrauterine fetal demise
5. Rotational forceps

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6. D&C in OR

f. All GYN admits will have a dictated discharge summary unless

admission is < 48 hours.
1. ONC residents dictate ONC patients.
2. GYN residents dictate benign GYN patients.
3. Any non-operative GYN admit to the GYN service that
is > 48 hours

4. Operative procedures that REQUIRE dictations:

a. All cesarean sections and operative vaginal deliveries.

b. All non-cephalic presentations delivered (regardless of route of
delivery, including breech, transverse, or other presentations).
c. All deliveries of multiple gestation (regardless of route of
delivery).
d. Serious complications of delivery, including complicated
laceration repair (fourth degree lacerations), postpartum D&C
for retained.
e. Placenta/obstetric hemorrhage, or any complication requiring
transfer of patient to the operating rooms on labor and delivery.
f. All gynecologic procedures in the operating room.

5. Operative procedures that DO NOT require dictations:

Outpatient uncomplicated D&C in the E.D. or Clinic 4.

Only a brief written operative note is needed.

6. Guidelines for dictating residents:

a. The discharging resident will dictate the discharge summary

(the one who fills out and signs the Final Discharge Order).
b. For surgeries, the primary operating resident will dictate the
operative procedure. If more than one resident is involved in
the case, the most junior resident will dictate the case.

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c. If there are any questions, please contact the Administrative
chief resident.

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DICTATION SAMPLES:

Post Partum Discharge Summary

Your name and title

Pt’s name
Pt’s date-of-birth
Pt’s MRN
Admit and d/c date
Referring MD (with address and phone # if transferred)
Attending MD (at time of discharge)

Final diagnoses (may include):

1. ___ week IUP
2. induction for ____ / PTL /failed induction/reason for c/s
3. NSVD/LTCS
4. ___ degree laceration
5. PP fever / UTI / urinary retention / benign postpartum course

HPI: Pt was a __yo G-P- with a __wk intrauterine pregnancy by

(LMP/US) who presented to L&D at time/day complaining of (reason for
admission off H&P – include LOF, ctx, bloody show, fetal movement, sx
of preeclampsia, fever, complications with pregnancy).

Past Hx: Illnesses, surgeries, allergies, medications, gyn hx, tobacco,

EtOH, drugs, transfusions, marriage status (all on H&P)

Antenatal Labs: type, Ab, rubella, etc (all on H&P)

PE: Vitals, exam, SVE, FHT, TOCO (all on H&P)

Admission Labs: whatever was ordered at admission

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Hospital course: The patient was admitted begun on IVF and EFM. The
patient’s labor progressed without any complications. (OR… was
complicated by NRFHT/arrest of dilation/arrest of descent and the patient
was taken to the OR for a primary/repeat LTCS). A liveborn infant
boy/girl with Apgars __ & __ was delivered at (time) weighing __ with
cord gasses of ___ and ____. A (epis, -degree lac) was repaired with
____. The patient was given (abx) for ___ during delivery/CS. The patient
was transferred to the postpartum unit in stable condition. Her postpartum
course was uncomplicated and she was sent home with the ability to
ambulate, spontaneously void, and eat without difficulty. Pt chose __ as
post-partum contraception. Antenatal Hct was __ and postnatal Hct was
__. Incisional staples were removed on POD __ and steri-strips were
applied. There were no signs or symptoms of infection or hemorrhage at
discharge.

* Include: postpartum fever, abx, hemorrhage, transfusions, any

diagnostics or treatments, etc.

Disposition: The patient was discharged home on PPD/POD __ with

instructions to limit heavy lifting to <15 lbs for 2 wks, insert nothing in
the vagina for 6 weeks including tampons, intercourse, and douching, and
to not drive while using narcotics. Pt was advised to call her MD for
T>100.4, increased vaginal bleeding > 1 pad/hour, foul lochia, increased
breast tenderness or redness, shortness of breath or chest pain, (increased
incisional pain, redness, or discharge), increased abdomen or leg pain, or
any other concerns. Patient was sent home on regular diet (ADA for
diabetics). Discharge medications included: (off d/c orders: pain meds,
colace or senna, FeSO4, PNV, contraception). Pt advised to follow-up in
6 weeks time for her postpartum check with Dr. __ at the ___ clinic (2
weeks time for wound check if CS, 2 weeks if family medicine patient or
SMC regardless of delivery route).

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Cesarean Section

Preopeative Dx
1. 24 yo G2P1001with 41 week intrauterine pregnancy
2. Failed post-dates induction
3. NRFHT / arrest of descent at _ / arrest of dilation at _
Postoperative Dx
1. same
2. s/p primary low transverse Cesarean section
Procedure: Primary low transverse Cesarean section via Pfannensteil
Surgeon: (attending’s name)
Assistants: (your name/rank, medical student’s name/rank)
Anesthesia: Epidural / Spinal

Indications: (be inclusive of details!) This 24 yo G2P1001 at 41 weeks

undergoing post-dates induction by regular-dose pitocin arrived at 1cm
dilation and was found to be 4cm after 6 hours. Fetal heart tones began
showing occasional deep variable decelerations at approx 0900 and
internal monitors were placed and the fetus recovered spontaneously. At
approx 1130 several pronlonged variable decelerations to the 60s were
noticed to last approx 60 seconds each and she was found to be 7cm
dilated, 90% effaced, and at -1 station. A prolonged deceleration lasting
2 minutes and unresponsive to nursing efforts led us to move to the OR
and take a emergent verbal consent from the pt for surgical intervention.
Fetal heart tones were noted in the OR to continue be in the 60s and we
proceeded with cesarean section.

Procedure: The patient was taken to the operating room where epidural
(spinal/general) anesthesia was found to be adequate. She was prepared
and draped in the normal sterile fashion in the dorsal supine position with
a leftward tilt. A Pfannensteil skin incisions was made with the scapel
and carried through to the underlying layer of fascia with the bovie. The
fascia was incised in the midline and the incision extended laterally with
the Mayo scissors. The superior aspect of the fascial incision was then
grasped with the Kocher clamps, evlevated, and the underlying rectus
muscles dissected off bluntly and with Mayo scissors. Attention was then

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turned to the inferior aspect of this incision which, in a similar fashion,
was grasped, tented up, and the rectus muscle dissected off. The rectus
muscles were then separated in the midline, the peritoneum identified,
tented up, and entered sharply with the Metzenbaum scissors. The
peritoneal incision was then extended superiorly and inferiorly with good
visualization of the bladder. The bladder blade was then inserted and the
vesicouterine peritoneum identified, grasped with the Russians and
entered sharply with the Metzenbaum scissors. This incision was then
extended laterally and the bladder flap created digitally. The bladder
blade was then reinserted and the lower uterine segment incised in a
transverse fashion with the scalpel. The hysterotomy was extended
laterally with bandage scissors (or digitally). The bladder blade was
removed and the infant delivered atraumatically. The nose and mouth
were suctioned with bulb suction and the cord clamped and cut. The
infant was handed off to the waiting pediatricians. Cord blood was sent
for gasses. The placenta was manually removed, the uterus exteriorized
and cleared of all clots and debris. The hysterotomy was repaired with 0-
chromic in a running locked fashion. A second layer of the same was
used to imbricate the incision and excellent hemostatis was noted after
several small Bovie cauterizations. The uterus was returned to the
abdomen, the gutters were cleared of all clots, and the abdomen irrigated
and sucked dry. Noting continued excellent hemostasis, the fascia was
reapproximated with 0-vicryl in a running fashion. The skin was closed
with staples and a bandage applied.
The patient tolerated the procedure well. Sponge, lap and
needle counts were correct times two. One gram of Ancef had been given
within 30 minutes prior to the procedure. The patient was taken to the
recovery room in stable condition.

Findings: Liveborn ____ infant with Apgars of ___, weight ___ grams.
Normal antomy of the uterus, tubes, and ovaries. Venous cord pH __ with
base excess __and arterial cord pH __ with base excess __.
EBL: ___
Fluids: ___
UOP: ___ (blood-tinged, clear, etc) urine
Complications: ___

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 - 108 -153108
Condition: Patient stable in recovery room and infant in well-born
nursery.

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 - 109 -153109
FORCEPS ASSISTED VAGINAL DELIVERY:

Pre-Op Dx:
Post-Op Dx:
Procedure: Low vs. Outlet FAVD with (type) forceps
Attending:
Assistant:
Anesthesia: epidural (…or spinal)

Indications: To include leading up to decision touse forceps plus,

maternal pelvimetry/assessment, anesthesia adequacy, EFW, position, e/o
asynclitism, caput/moldig, station, discussion of consent.

Procedure: Describe in detail, including, bladder drainage, bed broken

down, ansesthia confirmation, phantom application, type of forceps
applied by posterior without difficulty followed by anterior blade,
placement confirmation by multiple providers, with # of pulls through #
of CTXs, removal after crowing and remainder of delivery, repair, with
pediatrics present at delivery.

Findings: Infant, weight, Apgars, cord gas, placenta, lacerations/repairs,

examination of infant for markings (symmetry?)

EBL:
Complications: None
Condition: Patient stable in recovery room.

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Post partum Bilateral Tubal Ligation

Pre-Op Dx: 36 year old G9P8109 desiring permanent sterilization

Post-Op Dx: Same
Procedure: Postpartum tubal ligation, (Pomeroy, Parkland, etc… )
method
Surgeon:
Assistant:
Anesthesia: epidural (…or spinal)
Indications: This 36 year old G9P8109 is s/p VBAC and desiring
permanent sterilization. Risks, benefits, and alternatives were discussed,
including the risk failure rate of 3-5/1000 with increased risks of ectopic
gestation if pregnancy occurs.
Procedure: After consent was signed and placed in chart, the patient was
taken to the operating room where her epidural was found to be adequate.
A small transverse infra-umbilical skin incision was made with the salpel
and carried dwon through the underlying fascia until the peritoneum was
identified. The peritoneum was lifted up, entered sharply, found to be
free of adhesions and the incision extended with the Metzenbaum
scissors.
The left fallopian tube was identified, brought to the incision and grasped
with a Babcock clamp and followed out to the fimbria. The Babcock
clamp was used ro regrasp the tube approximately 4 cm from the corneal
region and a 3cm segment of tube was then ligated with a free tie of plain
gut and excised. Good hemostasis was noted and the tube was returned to
the abdomen. The right fallopian tube was then grasped, ligated, and a
3cm segment excised in a similar fashion. Excellent hemostasis was
noted and the tube returned to the abdomen. The peritoneum and fascia
were then closed in a single layer using 3-0 vicryl. The skin was sutured
in a subcuticular fashion using 3-0 vicryl before applying steri-stips and
and a bandage. The patient tolerated the procedure well and sponge, lap,
and needle counts were correct times two. The patient was taken to the
recovery room in stable condition.
Findings: Normal uterus, tubes, ovaries.
Pathology: Segments of right and left fallopian tubes
EBL: < 50 mL Fluids: 500 mL LR UOP: 50 mL, clear

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Complications: None
Condition: Patient stable in recovery room.

111
 - 112 -153112
Laproscopic Bilateral Tubal Ligation

Pre-Op Dx: 36 year old G3P3003 desiring permanent sterilization

Post-Op Dx: Same
Procedure: Laproscopic tubal ligation with Fishie clips
Surgeon:
Assistant:
Anesthesia: General endotracheal

Indications: This 36 year old G3P3003 desires permanent sterilization.

Risks, benefits, and alternatives were discussed, including the risk failure
rate of 3-5/1000 with increased risks of ectopic gestation if pregnancy
occurs.

Procedure: After consent was signed and placed in chart, the patient was
taken to the operating room where anesthesia was found to be adequate.
She was placed in the dorsal lithotomy position and prepared and draped
in a sterile manner. A bivalve speculum was placed in the patient’s
vagina and the anteriour lip of the cervix grasped with the single toothed
tenaculum. A uterine manipulator was advanced into the uterus and the
speculum removed. A 10mm skin incision was made in the umbilical
fold, the skin tented up, and the veres needle introduced into the
peritoneal cavity at a 90 degree angle. Intraperitoneal placement was
confirmed using a water-filled syringe. Pneumoperitoneum was obtained
with 4 litesrs of CO2 gas and the 10mm trocar advancedwithout
difficultry into the abdomen where intraabdominal placement was
confirmed by the laparoscope. A 5mm skin incision was made 2cm above
the pubic symphisis in the midline and a second trocar advance under
direct visualization. The pelvis and abdomen were surveyed and revealed
entrireely normal anatomy. The Fishie clip applicator was advanced
through the second trocar and the left fallopian tube indetified, followed
out to the fibfriated end, and the clip applied in the mid-sithmic area.
Good blanching was noted at the application site and there was no noted
bleeding. The Fishie clip applicator was reloaded and the right tube
ligated in a similar fashion. Again, good blanching was noted and there
was no bleeding. All instruments and trocars were removed from the

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abdomen and the infra-umbilical incision repaired with 3-O vicryl. The
uterine manipulator was removed from the vagina and the cervix was
noted to be hemostatic. The patient tolerated the procedure well. Sponge,
lap, and needle counts were correct time two. The patient was taken to
the recovery room in stable condition.

Findings: Normal uterus, tubes, ovaries.

EBL: < 100 mL Fluids: 1000 mL LR UOP: 50 mL, clear
Complications: None
Condition: Patient stable in recovery room.

UUMC DICTATION/CLINIC 4

www.evolvemed.com/univeristy
Phone 359-7782
Site# 71
ID#______________________ (same as UUMC ID#)
Work Types:
90 = New pt eval
91 = Follow-up note
92 = Procedure note
93 = Telephone note
94 = Ultrasound
95 = Letter
96 = non-clinical (admin)
Questions: 359-1621

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Dilation & Curettage

Pre-Op Dx: 23 year old G2P1001 with 7 week incomplete abortion

Post-Op Dx: Same
Procedure: Suction dilation and curettage
Surgeon:
Assistant:
Anesthesia: General endotracheal
Indications: This 23 year old G2P1001 presented to the E.D. two days
ago with vaginal bleeding and was found to have a positive urine beta-hcg
and incomplete abortion on bedside ultrasound. She was counseled to the
risks, benefits, and alternatives of surgical intervention and decided upon
a D&C.
Procedure: After consent was signed and placed in chart, the patient was
taken to the operating room where anesthesia was found to be adequate.
A sterile speculum was placed in the bagina and the cervix noted to be
1cm dilated with products of coneption present at the cervical os. A
single tooth tenaculum was then applied to the anterior lip of the cervix
and the uterus gently sounded to 9cm. An 8mm suction curette advanced
gently to the uterine fundus. The suction device was then activated and
the curett rotated to clear the uterus of the products of conception. This
maneuver was repeated several times until minimal bleeding was noted.
All instruments were removed from the vagina and hemostasis was noted
at the anterior lip of the cervix. The patient tolerated the procedure well.
Sponge, lap, and instrument counts were correct time two. The patient
was taken to the recovery room in stable condition.
Findings: 8 week sized uterus on exam, moderate products of conception.
Pathology: Products of conception sent for positive identification.
EBL: 150 mL Fluids: 500 mL LR UOP: 50 mL, clear
Complications: None
Condition: Patient stable in recovery room.

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Clinic Note – Annual Exam

Reason for Visit: Annual Exam

HPI: Miss Doe is 38-year-old G5, P2-1-2-3, who presents today for an
annual exam. She has concerns of a groin lump and needs refills of
thyroid medications.

PMHx: Hypothyroidism diagnosed in 1996.

PSHx: Tonsillectomy 1973. D&C 2002. LTCS 2003.

PGynHx: Menarch at age 12 with regular cycles every 28 days lasting 4-

5 days with light to normal flow. LMP is 9/7/2007. Last Pap smear 8/06,
normal. No history abnormal Pap smears. Condoms for contraception.
Monogomous heterosexual with boyfriend. No other partners since last
exam. Denies vaginal irritation, discharge or sexual concerns.

OBHx: 1997 – EAB at 10 weeks

2000 – 8lb 6oz male at 39 weeks by NSVD, no complications
2002 – SAB at 15 weeks, D&C
2003 – 6lb male at 34 weeks by Primary LTCS, PTL, NRFHT
2005 – 7lb 2oz female at 37 weeks by VBAC, no
complications

Meds: Levothyroxine 200mcg PO daily. St. Johns wart daily.

Allergies: NKDA

Social Hx: Divorced since 2006, living in Sandy with boyfriend and three
children. Lawyer for university. Social alcohol use (1/wk), but denies
cigarettes and illicit drugs.

Family Hx: Father deceased age 45 from AMI. Mother living with
hypothryroidism. Denies cancers of colon, cervix, uterus, ovaries. Breast
cancer in maternal aunt at age 67.

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Health maintenance: Lipid panel and labs of 2006 normal.
Mammograms and colonoscopy not yet indicated.

ROS: Significant for occasional stress headaches.

Constitutional: No malaise, fatigue, weight loss or gain.
Vision/Hearing: No blurry/double vision or lost hearing. Wear contacts.
Cardiovascular: No CP, palpitations.
Respiratory: No SOB, cough or sputum.
Musculoskeletal: No bone or joint pain/weakness.
Neurologic: No syncope, dizziness, tremors, or loss of sensation.
Gastrointestinal: No nausea, vomiting, diarrhea, constipation.
Genitourinary: No incontinence, dysuria, urgency, frequency.
Sexual: No dyspareunia.
Skin: No rashes, lesion.
Endocrine: No heat/cold intolerance, night sweats, polydipsia, polyuria.
Hematologic: No abnormal bleeding/bruising.
Psychiatric: No depression or anxiety.

PE: Vitals – weight 123lbs, BMI 24, BP 132/79, pulse 80, resp 24, T
36.5.
Gen: Well-dressed female in no acute distress.
HEENT: Pupils equal and reactive.
Neck: No thyromegally.
CV: Regular rhythm and rate, no murmurs, rubs, or gallops. No carotid
or femoral bruits.
Resp: Clear to auscultation and percussion bilaterally. No CVA
tenderness.
Breasts: No mass, tenderness, skin changes, nipple retraction or
discharge.
Axilla: No adenopathy, tenderness.
Abdomen: Soft, flat, positive bowel sounds. No tenderness to percussion
or palpation. No organomegally. Liver percusses to 8cm. Abdominal
aorta palpated to 2 cm.
Ext: No cyanosis, clubbing, edema; no superficial varicosities.
Skin: No rashes or suspicious growths.

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Neuro: CN 2-12 grossly intact. Intact peripheral DTRs.
Psych: Normal affect and mood.
Pelvic: External genitalia with normal appearance, no erythema or
lesions. Urethra without masses, tenderness, with normal motility.
Vaginal mucosa pink, moist, with rugae and physiologic discharge.
Cervix without lesions or ectropion, nontender. Uterus mobile,nontender,
midline; normal symmetry, contour; and size. Adnexa nontender without
masses. Perineal body with normal thickness and rectum without
hemorrhoids.

Labs:

Radiologic Studies:

A/P: 38-year-old G5, P2-1-2-3 presenting for annual exam with

complaint of a groin lump and needing medication refills.

1. Annual exam: PE and Pap performed. No changes in past year. Will

check lipid panel, CBC, and BMP today. Will mail negative results
and call her with any abnormalities. Discussed diet, vitamin
supplimentation and exercise strategies.
2. Groin lump: Normal variant of anatomy on exam and no evidence of
infection. Will recheck at next visit or she should return sooner if it
enlarges further.
3. Hypothyroid: Will recheck TSH today and adjust medication
accordingly. RF prescription given: Synthroid 125mcg PO daily, #90,
3 refills.
4. Pt to return to clinic in 1 year.
5. Patient was discussed in detail with attending Dr. X who agrees with
the above findings and plan.

Resident Doctor, MD

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COMMON MEDS USED IN PREGNANCY (BY GROUP):

Anti-Diarrheals
Kaopectate 30cc po after each stool -C
Lomotil 2 tabs po QID after each loose stool -C
Anti-Emetics
Meclizine 12.5-25mg po q 4-6 prn -B
Promethazine (Phenergan) 25mg po/pr q 6-8 prn -C
Prochlorperazine (Compazine) 5-10mg po TID-QID -C
Regal 10-15mg po QID 30 min AC/HS -B
Anti-Histamines/Decongestants/Antitussives
check for Etoh content before using
Diphenhydramine (Benadryl) 25mg q 6 prn -B/C
Clor-Trimeton 4mg q 4-6 prn -B
Clor-Trimeton timed release 8-12mg q 12 prn -B
Clor-Trimeton with Pseudoephedrine is C
Zyrtec 10mg po qd -B
Claritin 10mg po qd -B
Acifed, Allerest, Benadryl, Comtrex, Dimetapp, Seldane,
Sudafed -C
Robitussin plain or DM
Asthma
Albuterol (Proventil) MDI 2-4 puffs QID -C
Albuterol nebs .5 -C
Beclamethasone MCI 2 puffs TID-QID -C
Derm Preparations
Ring Worm/Fungal: Tinactin cream/lotion BID x2wks
Scabies: Eurax lotion /cream 2 x 24 hrs apart
(after 1st trimester) -C
Lice: A-200 Pyrinate lotion/ RID 2 x 24 hrs apart -C
Urticaria: Caladryl lotion
Benadryl 25-50mg po q 6-8 prn -B/C
Ear Infection
Augmentin 250-500mg po q8 -B
Ceftin 250-500mg po BID -B

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GERD/Gastritis
Prevacid (Lansoprazole) 15-30mg PO daily
Nexium (Esmomeprazole) 20-40mg PO/IV daily
Zantac (Ranitidine) 150mg PO BID or 300mg qHS -B
Pepcid (Famotidine) 20mg PO/IV BID -B
Reglan 10-15 mg po QID 30 min AC/HS -B

Headaches/Migraine
Tylenol 650mg po q 6-8 prn -B
Compazine 5-10mg po TID-QID -C
Inderal LA 80mg qd -C
Hemorrhoids
Anusol HC supp BID prn -C
Xylocaine ointment 2% topical prn -B
Insomnia
Benadryl 25-50mg po q HS prn -B/C
Vistaril 50-100mg po q HS prn -C
Laxatives
Colace 100mg qd-BID prn -C
PeriColace 1 po qd-BID prn –C
Milk of Magnesia 30ml PO with meals until BM
Pain Meds
Vicodin 5/500 1-2 po q6 prn -C
Percocet 5/325 1-2 po q6 prn –C
Lortab 5/500mg 1-2 tabs PO q 6 hrs PRN – C
Norco 7.5/325mg 1-2 tabs PO q 6 hrs PRN – C
T#3 1-2 po q6 prn -C
T#4 1 po q6 prn –C
Flexeril (Cyclobenazaprine) 15mg 1-2 tabs PO daily
Sinusitis/URI
Z-Pack 500mg po D1, 250mg po D2-5
Augmentin 250-500mg TID x 14-21d -B
Ampicillin 500mg po QID x7 -B
Erythromycin 400mg po QID x 7d (EryC=250mg delayed
release cpsl) -B
Keflex 500mg po QID x 7d –B

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Strep Throat
Amoxicillin 250mg po TID x 10d -B
PNC LA (Bicillin) 1.2 million units IM x1 –B or sinusitis
meds
UTI’s
Macrobid 1 po BID x 7-10d -B
Macrodantin 100mg po QID x 10d (100mg qHS, suppression)
-B
Amp 500 po QID x 10d -B
Keflex 500mg po QIDx10 -B
Pyridium (Phenazopyridine) 100mg 1-2 tabs PO TID x 2-3d –
B

OTC med allowed:

Tylenol
Benadryl
Sudafed
Robitussin DM
Preparation H
Tums
Rolaids
Pepto-Bismal
Thera-Flu

OTC meds to AVOID:

Aspirin
Advil / Motrin / Ibuprofen
Nyquil

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Most combo cold preparations

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BIRTH CONTROL: UUMC Price

Ortho Micronor 1 tab PO daily as directed $

Disp #1 pack per month, RF #6
* if breast-feeding

OrthoEvra 1 patch q week x 3 weeks, 4th week no patch $

Disp #3 patches, RF #6, extra patch PRN

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COMMON MEDS USED BY ANYONE (BY GROUP):

Antibiotics

Ampicillin 2 gm IV q 6 hrs (GBS)

2 gm IV now, then 1 g q4 hrs (GBS)
Amoxicillin: 500 mg PO TID
Ancef 2 gm IV now, then 1 g q8 hrs (GBS)
Augmentin 875 mg PO BID
Azithromycin: 500 mg PO loading dose x 1
250 mg PO daily
Clindamycin 900 mg IV q 8 hrs (GBS)
Dicloxacillin 500 mg PO QID x 10-14 days, then Augmentin
Diflucan 150 mg PO x one
Doxycycline 100mg PO BID x 5-7 days
Erythromycin: 250 mg IV q8 hrs
333 mg (base) PO q6 hrs or TID
500 mg IV q8 hrs (GBS)
Gentamycin 120 mg IV x one, then 100 mg IV q 8 hrs
-- order peak & troughs with 3rd dose and follow-up
-- call in-patient pharmacy to calculate adjustments
Macrobid 100 mg PO BID
Metronidazole 500 mg PO BID
Metrogel 0.75%gel BID x 5 days
Monistat 2% cream q hs x 7 days (100 mg supp)
Penicillin 5 mil units IV x 1, then 3 mil units q 4 hrs (GBS)
Terazol 0.4% cream q hs x 7 days
-- (0.8% cream x 3 days, 80 mg supp. X 3 days)
Unasyn (Amp/Sulbactam)
1.5 or 3 grams IV q 6 hrs
Vancomycin: 1 gm IV q12 hrs (GBS)
Zosyn 3.375g IV q 8hrs

“GI Prophylaxis”: Cefoxitin 2g IV q6hrs x 48hrs

Flagyl 500mg IV q8hrs x 48hrs

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Tocolytics
Indomethacin 50 or 100 mg PR loading dose x 1
then 25 or 50 mg PO q 6 hrs for total of 8 doses
(*Not if fetus older than 32 weeks or Oligo*)
Nifedipine 20mg PO loading dose x 1 (up to q 20min x 3
doses)
Then 10-20 mg PO q6 hrs (hold for BP < 90/50)
Terbutaline: 0.25 mg SQ q 20 minutes x 3
(hold for pulse > 120)
5mg 1-2 tabs PO q 4-6 hrs PRN
Mag.Sulfate: 4 gram IV load, then 2 grams/hr
6 gram IV load, then 3 grams/hr
Nitrous Oxide 100mcg IV q 20 min (?)

Antihypertensives, emergency
Hydralazine 5 mg IV
Repeat BP q 5 minutes x 20 minutes.
May repeat as 5 or 10 mg q 20 minutes.
Labetolol 20 mg IV
Will respond in 10-15 min (quicker than
hydralazine)
May repeat doses as 40, 60, 80, and 80.

Pain:
Tylenol: (Acetaminophen – 325 mg)
1-2 tabs PO q4 hrs PRN pain
Motrin: (Ibuprofen)
800mg PO TID – either prn or scheduled
Tylenol #3 (Acetaminophen/Codeine – 300/30)
1-2 tabs PO q 3 hrs prn pain
Percocet (Oxycodone/Actetominophen – 5/325)
1-2 tabs PO q 3 hrs prn pain
Lortab (Hydrocodone/Acetaminophen – 5/500)
1-2 tabs PO q 4 hrs prn pain
Fentanyl: 50-100 mcg IV q1 hr PRN pain

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Postpartum Atony
Pitocin 30 units/500 cc
Cytotec 800 mcg PR
Hemabate 0.25 mg IM or intrauterine (no in asthmatic)
Methergine 0.2 mg IM (no if hypertensive)

Induction agents
Pitocin Reg-dose or High-dose
Cytotec 25 mcg PV q 4 hours
200 mcg PV q 4 hours – for termination/induction

Vitamins / Suppliments / Other

Methotrexate 50 mg/m2 IM (ectopics which meet criteria)

Oxybutynin 2.5-5 mg TID
Ditropan XL 5, 10, or 15 mg PO QD
Detrol 1-2 mg PO QD or BID
Betamethasone 12 mg IM q 24 hours x 2 doses (FLM)
Dexamethasone 6 mg IM q12 hours x 4 doses (FLM)
Dexamethasone 10 mg IV q 6 hours x 4 doses (for severe HELLP)
DdAVP 0.3 mg/kg-infuse over 30 minutes Q 12 hrs.
If no response, then cryoppt.
Use ddAVP in VonW DZ if Factor 8 activity <
25%.
Anusol suppositories: (Hydrocortisone 25mg)
1 PR BID prn for perneal discomfort
Epifoam: (Hydrocortisone 1% & Pramoxine 1%) – self-med
Topical to perineum QID for perineal discomfort
Tucks: (Witchhazel pads) – self-med
To perineum PRN for discomfort
Maalox: (Aluminum hydroxide / Habnesium hydroxide)
30mL PO q4 hrs PRN heartburn
Tums: (Calcium carbonate 500mg)

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2 tabs PO q2 hrs PRN heartburn
Milk of Magnesia: 30mL PO TID PRN constipation
Ferrous Sulfate: 325mg PO with meals BID
Docusate: 100mg PO BID PRN constipation
Folate (Folic acid) 0.4mg PO daily (daily RDA)
4mg PO daily (if NTD risk) – as 1mg 2 tabs PO
BID
Liquid Iron “Niferex” elixir; 100mg/5ml with 10% EtOH
Liquid MVI “Centrum” OTC

Heparin 5000 units SQ TID (start ~6 hrs after surgery)

7500 units SQ BID
Lovenox 40 units SQ daily (start ~6-12 hrs after surgery)

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ALPHABETICAL LIST OF COMMONLY USED MEDS:

Albumin gtt: Mix 12.5 g albumin in 1000 cc NS

infuse at 125 cc/hr

Ambien: (Zolpidem)
5-10 mg PO QHS

Ampicillin: GBS prophylaxis = 2 g IV load, then 1 gm IV q 4

hrs
Start 12-18 hrs ROM at term if not yet delivered
Endomyometritis = 2 gm IV q 6 hrs + Gent
Gentamycin = 120 mg IV load then 80-100 mg q 8
Or… 1.5 mg/kg load with 1-1.7 mg/kg maintenance

Ancef: (Cefazolin)
Ongoing tx = 0.5-1.5 gm IV q 6-8 hrs
C-section = 1 gm IV at cord clamp
Gyn surg px = 2 gm IV OCTOR

AZT: 2 mg/kg IV load over 1 hr

then 1 mg/kg/hr until delivery

Azithromycin: 1 g PO x 1

Betamethasone: 12.5 mg IM q 24 hr x 2 (for 24-34 wks)

Repeat if 1st dose at 24-28 wks and now > 28 wks

Bisacodyl: (Dulcolax)
10-15 mg PO PRN
10 mg PR PRN daily until BM

Butorphanol: (Stadol)
1-2 mg IV q 1-2 hr PRN pain

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Ceftriaxone: (Rocephin)
125 mg IM x 1 for NG/Chlamydia
250 mg IM x 1 for PID

Clindamycin: 900 mg IV q 8 hrs / 450 mg PO q ?

1 applicator QHS x 7 days
1 suppository per vagina QHS x 3 days

Colace: 100 mg tab PO daily PRN constipation

Cytotec: 200 mcg PV q 4 hrs

1-2 tabs PV q6 for terminations / IUFD deliveries
For term induction, refer to protocol

Cytotec: (Misoprostol, PGE1)

25-100 mcg per vagina q 3-4 hr
Max 500 mcg / 24 hr

DepoLupron (GnRH agonist)

3.75mg IM q month
11.25mg IM q 3 months

Dexamethasone: 6 mg IM q 12 hr x 4 doses
* for FLM (fetal lung maturity)

Diflucan: 150 mg PO x 1 for yeast vaginitis

Cervidil: (Dinoprostone, PGE2)

10 mg to floor
Per post fornix q 12 hrs until ripe or PRN
discomfort

Doxycycline: 200 mg PO load

then 100 mg PO BID for 5-7 days following D&C

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ESTROGEN:

Vagifem 1 tab PV 2x/wk (8 tabs/box)

1 tab PV qHS x 2 wks then 2x/wk
Estring 1 ring q 3 months
Premarin Cream 1g = 0.625mg (absorb 50%)
Estrace Cream 1g = 0.1mg  2g PV daily
0.01% cream

ELECTROLYTES:
Mg++ 400-800mg PO magnesium oxide (may cause
diarrhea)
1g (1.5-1.9) to2 gm (1.2-1.4) magnesium sulfate IV
PO4 K-Phos Neutral 250mg PO TID (high Na, low K)
Neutra-Phos 75ml TID (mod Na, mod K)
Neutral-Phos K 75ml TID (no Na, high K)
15mmol (1.5-2.0) to 30 mmol (1.0-1.5) KPhos IV
K+ 40 mEq KCl in 500 NS over 4 hrs
* each 10 mEq increases K+ 0.1
K-Dur 40 mEq PO
Ca++ 500mg PO calcium carbonate (Tums)
1-2 g IV calcium gluconate

Fentanyl: 50-100 mcg IV push for conscious sedation

(max 300 mcg)

Ferrous Sulfate: 325 mg PO daily for anemia

Fluconazole: 150 mg PO x 1 (* as effective as topicals)

Gentamycin: 120 mg IV load then 100 mg IV q 8 hrs

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Check the pt’s renal fxn and wt, but most can
tolerate:
Once daily dosing available, call pharm
Check levels (30min after 3rd dose and before 4th)
Use with Ampicillin for chorioamnitis and SBE px

Hemabate: 1 amp 0.250 mg IM (carboprost, PGF2a)

* Avoid in asthmatics

Hydralazine: 10-20 mg IV q 30-60 min for BP > 180/100

Heparin protocol: Mix 24000 units in 1L NS and run at 50 cc/hr

Ibuprofen : 800 mg PO q 8 hr with food PRN pain (motrin)

Indomethacin: Start 50-100 mg PO/PR

Then 25 PO/PR q 6-12 hr up to 48 hrs

Insulin gtt: Mix 50 units reg insulin in 500 cc NS

Start infusion a 1 unit/hr
Check FSBS q hr and titrate accordingly
* use mainline dextrose fluid initially
Ketoconazole: 400 mg PO daily x 7 days (or 14 days)
* recurrent yeast vaginitis
Labetolol: 20 mg IV q 10-20 min
May increase to 40-80 mg after 1-2 doses
Max 300 mg/day for BP > 180/100
Lactulose: 15-30 mL PO TID/QID

Macrobid: (Nitrofurantoin)
100 mg PO BID x 7-10 days for UTI

Magnesium Sulfate: Mix 4 gm MgSO4 in 100 cc NS IV bolus

Then mix 40 gm MgSO4 in 1L NS and run 2 gm/hr
IV
* for PTL tocolysis or seizure px

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Milk of Magnesia: 30-60 mL PO as laxative (Magnesium hydroxide)

5-15 mL PO QID PRN as antacid

Meperidine: 25-75 mg IV q 1-2 hrs PRN pain (Demerol)

Metclopromide: 10 mg IV/PO TID for N&V (Reglan)

Methergine: 1 amp 0.2 mg IM (Methylergonovine)

0.2 mg PO q 6 hr x 24 hrs following D&C (HTN!)
Methotrexate: 50 mg/m2 BSA
then Cytotec 400 mcg 48-72 hrs later q 6 hrs
* until POC expelled for SAB

Methyldopa: (Aldomet)
250 mg PO BID-TID, up to 3000 mg/day

Metronidazole: Trich = 2 gm PO x 1
BV = 500 mg PO BID x 7 days
500 mg IV q 12 hrs
BV(preg) =250 mg PO TID x 7 days
* Disulfuram effect
Morphine: 2-4 mg IV q 2-4 hrs PRN pain

Nalbuphine: 5-10 mg IV q 3-6 hrs PRN pain

Nifedipine: (Procardia)
10 mg PO (not SL) for immediate BP control
Max 120 mg/day
Procardia XL 30-90 mg PO daily

Prilosec: (Omeprazole)
20-60 mg PO daily

Pitocin: (Oxytocin)

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Mix 20 units in 1L NS
Begin 1-2 mu/min
Increase 1-2 mu/min q 15-30 min
Max 35 mu/min

Protonix: 40 mg PO daily
Penicillin G: 5 million units IV load
then 2.5 million units IV q 4 hrs
until delivery for GBS px

Premesis-Rx: (Vit B6 / Folate / B12 / CaCO3)

100 mg PO daily for hyperemesis

Prevacid: (Lansoprazole)
15-30 PO daily (or IV)

Promethazine: 12.5 – 25 mg IV/PO/PR q 6 hr PRN N&V

Phenergan Disp #20, RF #0

Prenatal Vit: 1 tab PO daily

Disp #30, RF #2
Propoxyphene/Acet: (Darvocet N-100)
1-2 tabs PO q 4-6 hrs PRN pain, max 6 tabs/24hrs

Reglan: (Metclopromide)
To induce milk production – 10 mg tabs, disp #33
D1 1 tab PO daily
D2 1 tab BID
D3-11 1 tab TID
D12 1 tab BID
D13 1 tab PO daily
* keep record of production, should see results by D5

RhoGAM: 1 vial (300 mcg) IM with 72 hr if mother Rh(-)

Simethicone: (Mylicon)

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80 mg PO q meals and QHS

Terconazole:
Terazol-3: 0.8% cream – 1 applicator per vagina QHS x 3 day
Terazol-7: 0.4% cream – 1 applicator per vagina QHS x 7 days
Terazol suppository: 80 mg per vagina QHS x 3 days

Terbutaline: 0.25 mg IM q 30 min

Max 1 mg in 4 hrs for tachysystole

Thorazine: 12.5 – 25 mg PO BID for ptyalism

Tioconazole: 1 applicator per vagina QHS x 7 days

(Monistat) Disp #7, RF #0

Toradol: 30 mg IV q 6 hr PRN pain (ketorolac)

Unasyn: 3 gm IV q 6 hr

Versed: (Midazolam)
1 mg slow IV push for conscious sedation
Repeat q 2-3 min
Max 5 mg

Zofran: 8 mg IV q 6-8 hr PRN N&V

24-32 mg IV daily for chemo N&V

Zosyn: 3.375g IV q 8hrs

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PCA ORDERS:

Meperidine

Demerol 30 mg bolus

15 mg dose
15 min lockout
60 mg/hr max

Hydromophone 0.7 mg load bolus

Dilaudid 0.3 mg dose
10 min lockout
1.8 mg/hr max

Morphine 3-4 mg bolus

MS Contin 1 mg dose
10 min lockout
6 mg/kg lockout

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TELEPHONE NUMBERS

University (Prefix 581 or 585 or 587)

Information 12121
Ronalee Ellis 17647
Dept Fax 55146
Natalie Moore 15501

L&D: 12452
L&D Fax: 52108
L&D Physican Lines: 12919
59938
OBES: 79500
2 North: 12261
2 East: 12356
Well Baby Nursery: 12663
NBICU: 12747
GENETICS: 17825
L&D Social Workers: Nomi 339-5130 or Tamar 339-5265
Interpreters: 339-2897

OB Anesthesiology: 339-3989 (pager)

581-2715 (sleep room)
581-5931 (work room)

OB Diagnostics (appts): 17746

52894 & 52893 (back room)

PCMD PEDS CARDS: 662-5400 (office)

662-5403 (fax)

SOUTH MAIN CLINIC: 468-3690 (front desk)

468-3373 (Lee Cherie)
________ (fax)

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Clinic 4: 12719 (appts)
12695 (front desk)
12010 (RN line)
12515 (work room)
Clinic 4 FAX: 51790

Utah Diabetes Center : 587-3913

Project Reality: 364-8080 (FAX:364-8098)
PREGNANCY RISK LINE: 328-2229
UT Domestic Violence Hotline: 800-897-link
GYN Ultrasound: 12529

Main OR scheduling: 12602

ER: 12292
OR: 12211
MICU: 12434
4N: 12848
6N: 12381
6S: 12371
5W: 12811 (MD only)

LAB: 12430
MICRO: 12484
BLOOD BANK: 12331

PHARM -Out Pt: 12276

Out Pt: 12166 (MD only)
PHARM – In Pt: 52330
PHARM – Rx Info: 12073
PHARM – 2N/2E pager: 339-5750

Tubal Authorization: 213-3800

MED RECORDS: 12353

PowerChart info: 12790

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Oncology:

Onc # for patient appts: 585-1000

585-0640
Nancy (Dr. Soisson's RN): 581-3552
Nereida (New patient coordinator): 587-4399
Work room 585-0250
Huntsman 4th floor : 581-2436
Huntsman 5th floor: 587-4448
Huntsman OR front desk: 587-4300

LDS back room 408-2256

LDS appts 213-2239

Radiology:

Anne Kennedy 339-5202

Paula Woodward 339-
Abd U/S: 12929
CT inpatient: 18170
CT outpt: 17840
Diagnostic: 12307 (12306)
File Room: 12350
MRI: 17840
MRI/CT/IVP Scheduling: 17840
IR (on call): 339-5210

Huntsman Mammograms/DEXA:
74248 – or – 15496
Fax: 52292

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UUMC Dictation line: 5-9202 (in-house) or 585-9202 (outside)
 ID # ___________________
 “2” begin/hold/restart
 “3” Rewind
 “4” Continuous forward
 “5” end and get job#
 “6” STAT
 “7” go to beginning
 “8” end and begin another dictation
 Work type
1 = Op note
2 = Discharge Summary
3 = H&P
5 = Consultation
7 = Death Summary

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LDS (Prefix 408)

GYN Resident Pager: 339-6989

Info: 1100
4 West: 2458
6 North: 7600
8 East: 3858
ER: 1181
ER Fax 3185
Med Records: 1161
Radiology: 1791
OR: 3340
OR scheduling: 3345
Outpatient Pharmacy: 1018
Oncology Office: 2251

Resident Room: 3380

(door code: 10770)

LDS/IHC Dictation :
Dial # 6123 (inhouse) or 442-4000 (outside)
Facility code = 128
Work Type :
2 = Pause
1 = H&P
3 = Rewind
2 = Consult
4 = Forward
3 = Op note
5 = End and disconnect
4 = Discharge
6 = STAT
8 = Transfer summary
8 = End and New
15 = Outpatient clinic note
9 = Suspend
51 = Interim summary
81 = Surgery center H&P
82 = Surgery center Op Note

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IMC (Prefix 507):

OB Resident Pager: 202-4860

L&D: 507-7777
Main Hospital: 507-7000
MFM and Diagnostics: 507-7400
Maternity 2: 507-7200
Maternity 3: 507-7300
NICU: 507-7510
Interpreter Day: 241-0850
Interpreter Night: 249-3390
Lab: 507-2110

Resident Room Code: 202486

Dictation: *0333 (facility code 154)

3 = Op note
4 = discharge

IMC/IHC Dictation :
Dial *0333 (inhouse) or ____________ (outside)
Facility code = 154
Work Type :
1 = H&P
2 = Consult 2 = Pause
3 = Op note 3 = Rewind
4 = Discharge 4 = Forward
8 = Transfer summary 5 = End and disconnect
15 = Outpatient clinic note 6 = STAT
51 = Interim summary 8 = End and New
81 = Surgery center H&P 9 = Suspend
82 = Surgery center Op Note

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FACULTY

Perinatology

Andres, Bob: (801) 589-0748 (cell)

Branch, Ware: 339-8584
Byrne, Jan: 339-8372
Clark, Erin: 339-0031
Draper, Michael: 339-2363
Dizon-Townson, Donna: (888) 444-4552
Esplin, Sean: 339-3600
Grosvenor-Eller, Lexi : 339-6536
Jackson, Mark : 202-0441
Major, Heather: 339-9188
Manuck, Tracy: 339-9393
Porter, T.Flint: (801) 718-7848 (cell)
Rose, Nancy: 241-6562
Silver, Bob: 339-4740
Sullivan, Amy: 339-4739
Varner, Michael: 339-6753
______________ ________
______________ ________
______________ ________
______________ ________

Gyn-Onc

Dodson, Mark: 339-6837

Soisson, Pat: 339-4914
Webb, Joel 339-0863
Janat-Amsbury, Margit: 339-1981
Hunn, Jessica: 339-3240
___________________ ________
___________________ ________

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General

Chaudhari, Angela: 339-6574

Rose, Susan: 339-4995
Scott, James: 583-6000
Sharp, Howard: 339-6814
Summers, Paul: 339-4741
Turok, David: 339-8240
Van Horn, Jenny: 339-3663
Wheeler, Catherine 339-2542
Wilder, Stephanie 339-7212
____________________ ________
____________________ ________

REI

Gibson, Mark: 339-6894

Gurtcheff, Shawn: 339-1774
Hammoud, Ahmad: 339-5473
Hatasaka, Harry: 339-6850
Jones, Kirtly: 339-6737
Milroy, Colleen: 339-2290
Peterson, Matt: 339-6913
_____________________ ________
_____________________ ________

Uro-Gyn

Norton, Peggy: 339-7070

Nygaard, Ingrid: 339-7689
Clinic 74888
Back room 74842
Appts 13565
_____________________ ________
_____________________ ________
_____________________ ________

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LOGINS / PASSWORDS: (UUMC ITS Support Desk: 581-6100)

UUMC PowerChart: _______________

_______________
UUMC PACS (radiology) _______________ Try: pacs
_______________ pacs
Trace View (L&D) _______________
_______________
LDS Help _______________
_______________
LDS Help2 _______________
_______________

ACGME (case log) _______________

www.acgme.org/residentdatacollection _______________

E*Value (duty hours) _______________

www.e-value.net/index.cfm _______________

Remote UUMC Login

_______________
http://remote.med.utah.edu _______________

Call Schedules: Site: docs.google.com

Login: utahobgyn
PW: google

Copier codes: 2N _____ _____ _____

Ob/Gyn _____ _____ _____

UUMC ED Door Code: ______________________________

UUMC Long Distance Phone Access #: __________________

UUMC Scrub Locker#: ______ Code:___________________

UUMC Scrub Locker#: ______ Code:___________________

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UUMC Scrub Locker#: ______ Code:___________________

146
 - 147 -153147
PAGER NUMBERS

Resident Birthday Pager

Bennett, Michele: 05/16 339-0204

Davis, Sarah: 11/05 339-7723
Meltzer, Nathan: 03/21 339-6142
Moore, Hillary: 03/29 339-7222
Zarek, Sarah: 12/02 339-7310

Bennett, Donna: 01/30 339-3325

Dorais, Jessie: 03/24 339-2115
Haakenson, Caroline: 06/11 339-4598
Pawasarat, Julie: 10/27 339-2106
Pittman, Jessica: 08/21 339-4103
Yi, Johnny: 10/14 339-5463

Jacob Calvert: 12/10 339-6122

Mallorie Evenson _______
Jamie Lo: 5/29 339-9998
Erin Morris: 4/10 339-2814
Marilee Simons: 8/21 339-2743
Carolyn Swenson: 6/13 339-3215

William Baker
Welles Henderson
Bridget Kamen
Megan Link
Ben Mize
Amelia Parrett

UUMC Antepartum PAGER: 339-6178

UUMC Postpartum PAGER: 339-5981
UUMC GYN/ER PAGER: 339-6018
LDS on-call PAGER: 339-6989
IMC on-call PAGER: 202-4860

147
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NOTES

148
 - 149 -153149
NOTES

149
 - 150 -153150
NOTES

150
 - 151 -153151
NOTES

151
 - 152 -153152
NOTES

152
 - 153 -153153
NOTES

153