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FETAL BIOMETRY CONGENITAL ANOMALY SCAN
Biparietal Diameter (BPD) Done at 18-20 weeks AOG
Head circumference (HC) Indications:
Abdominal circumference (AC) o Maternal Age
- Least reliable in terms of aging because it is made out of o History of Previous Child with congenital anomaly
soft tissue o Family history of congenital anomaly
- Most important parameter in determining fetal weight
Femur Length (FL)
- Most reproducible
BIOPHYSICAL SCORING
LEOPOLDS MANEUVER
The first three maneuvers are done with the examiner facing the patients
head. The final maneuver is done with the examiner facing the patients feet.
1. The first maneuver (Fundal Grip) permits identification of which On which side is the fetal back?
fetal polethat is, cephalic or podalicoccupies the uterine
fundus. 3. The third maneuver (Pawliks Grip) is performed by grasping
- BREECH: large, nodular mass with the thumb and fingers of one hand the lower portion of the
- HEAD: round, movable, ballotable mass maternal abdomen just above the symphysis pubis.
- TRANSVERSE: empty - NOT ENGAGED: easily displaced, round, ballotable mass
- ENGAGED: Fixed, knob-like part
What fetal pole occupies the fundus? What fetal part lies above the pelvic inlet?
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4. To perform the fourth maneuver (Pelvic Grip), the examiner
faces the mothers feet and, with the tips of the first three fingers
of each hand, exerts deep pressure in the direction of the axis of
the pelvic inlet. In many instances, when the head has
descended into the pelvis, the anterior shoulder may be
differentiated readily by the third maneuver.
- HEAD FLEXED: cephalic prominence on the same side as
the fetal small parts
- HEAD EXTENDED: cephalic prominence is on the same
side as the fetal back
CLINICAL PELVIMETRY
BASELINE VARIABILITY
Fluctuations in the baseline FHR which are irregular in amplitude and
frequency.
Visually quantified as the amplitude of peak-to- trough in beats per
minute
- Absent: amplitude range undetectable
- Minimal: amplitude range detectable but 5 bpm or fewer
- Moderate (Normal): amplitude range 6-25 bpm
- Marked: amplitude range >25 bpm
CARDIOTOCOGRAM (CTG)
Accurate FHR assessment may help in determining the status of the
fetus and indicate management steps for a particular condition. In
order to accurately assess a FHR pattern, a description of the pattern
should include qualitative and quantitative information in the following
five areas:
1. Baseline rate
2. Baseline FHR variability
3. Presence of Accelerations
4. Periodic or episodic decelerations
5. Changes or trends of FHR patterns over time
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- Due to head compression
LATE DECELERATIONS
- In association with a uterine contraction, a visually apparent,
gradual (onset to nadir 30 sec or more) decrease in FHR with
return to baseline
- Onset, nadir, and recovery of the deceleration occur after the
beginning, peak, and end of the contraction, respectively
- Indicates uteroplacental insufficiency
ACCELERATION
A visually apparent increase (onset to peak in less than 30 sec) in
the FHR from the most recently calculated baseline
- The duration of an acceleration is defined as the time from the initial
change in FHR from the baseline to the return of the FHR to the
baseline
- At 32 weeks of gestation and beyond, an acceleration has an
acme of 15 beats per min or more above baseline, with a duration of
15 sec or more but less than 2 min
- Before 32 weeks of gestation, an acceleration has an acme of 10
beats per min or more above baseline, with a duration of 10 sec or
more but less than 2 min
- Prolonged acceleration lasts 2 min or more, but less than 10 min
- If an acceleration lasts 10 min or longer, it is a baseline change
VARIABLE DECELERATIONS
- An abrupt (onset to nadir less than 30 sec), visually apparent
decrease in the FHR below the baseline
- The decrease in FHR is 15 beats per min or more, with a duration
of 15 sec or more but less than 2 min
- due to by cord compression
DECELERATION
- Transient episode of slowing of the FHR below the baseline
level of more than 15 bpm and lasting 15 sec or more.
- If rate is below 110 bpm and duration is >10min:
BRADYCARDIA PROLONGED DECELERATION
EARLY DECELERATIONS
- Visually apparent decrease in FHR below the baseline, 15 bpm
or more, lasting 2 min or more but less than 15 min in duration.
- In association with a uterine contraction, a visually apparent,
gradual (onset to nadir 30 sec or more) decrease in FHR with SINUSOIDAL PATTERN
return to baseline
- Visually apparent smooth, sine wave-like undulating pattern in
- Nadir of the deceleration occurs at the same time as the peak of FHR baseline with a cycle frequency of 3-5 bpm which persists
the contraction for 20 min or more
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2. Sudden gush of blood
3. Uterus rises in the abdomen
UTERINE CONTRACTIONS 4. Lengthening of the umbilical cord
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Arrest in Cervical Dilatation
VAGINAL SPONTANEOUS DELIVERY
1. Aseptic Technique
2. Drape the patient
3. Place in dorsal lithotomy position to increase the diameter of the
pelvic outlet
4. Inject anesthesia on the site of episiotomy
5. Do episiotomy
6. Ritgen Maneuver with perineal support
7. Slide hand along the neck to check for nuchal cord
8. Wipe babys face
9. Pull head downwards
10. Pull upward once the anterior shoulder is seen
11. Deliver the baby
12. One hand supports the head, the other slides along the back to
grasp the feet
13. Put plastic clamp or tie tightly around cord at 2 cm and the
forceps 5 cm from babys abdomen. (Clamp and cut cord after
cord pulsations stop) Arrest in Descent
14. Cut between ties with a sterile instrument
15. Dry and wrap the baby
16. Give the baby to the Pedia for ENC
PLACENTAL INSPECTION
1. Inspect for blood vessels: two arteries, one vein (AVA)
2. Cord length (Williams: Most umbilical cords are 40 to 70 cm
long)
- Check for true knots, false knots, kinks, clots
3. Type of insertion
- Central, paracentral, peripheral, velamentous
4. Arborization of vessels over the fetal surface
- Vessels should taper toward the edge
- If exceeds up to outer 1/3, suspect accessory lobe
5. Check the fetal membranes
- Amnion: fetal side with vessels Prolonged Deceleration Phase
- Chorion: maternal side; avascular
- If yellowish, indicates chorioamnionitis
6. Check for completeness of cotyledons (Normal: 10-38)
7. Check for infarction (placenta previa), hematoma (abruption
placenta), hemorrhages, flattening
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EPISIOTOMY Storage Duration of Fresh Human Milk for Use with Healthy Full
Episiotomy: incision of the pudendumthe external genital Term Infants: (Reference: CDC)
organs
Perineotomy: incision of the perineum
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DILATATION AND CURETTAGE Steps in Doing Fractional Curettage
Types of Curettage: 1. Identify patient, explain the procedure, place in dorsal
1. Completion Curettage lithotomy position under sedation
- Therapeutic 2. Aseptic technique
- For obstetric cases (e.g. abortion, retained placenta) 3. Drape
- Steps: Sound Endometrial Resound 4. Bladder catheterization
- Instruments (you must be able to identify): 5. IE for corpus size determination and orientation (cervix
a. Vaginal retractor anterior or posterior?)
b. Tenaculum forceps 6. Apply posterior vaginal wall retractor
c. Ovum forceps 7. Grasp the anterior lip of cervix using tenaculum forceps
d. Sharp curette 8. Proceed with endocervical curettage using the smallest
e. Uterine forceps curette until enough specimen is acquired. Put aside
f. Hysterometer 9. Initial uterine sounding using hysterometer; corresponds
to uterine depth
10. Proceed with endometrial curetting. Curette until gritty
(endometrium) and bubbly (arterial blood vessel)
11. Final uterine sounding
12. Remove instruments
13. Final asepsis
14. Patient tolerated the procedure well
FORCEPS DELIVERY
Basic Design of Obstetric Forceps
2. Fractional Curettage
- Both diagnostic and therapeutic
- For gynecological cases (e.g. AUB, myoma)
- Obtain endocervical and endometrial curettings
- Steps: Endocervical Sound Endometrial
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6. There should be no suspected cephalopelvic disproportion.
TYPES OF FORCEPS:
4. For the application of the right blade, two or more fingers of the
left hand are introduced into the right posterior portion of the
vagina to serve as a guide for the right blade.
5. This blade is held in the right hand and introduced into the vagina
as described for the left blade.
6. After positioning, the branches are articulated and locked.
Traction:
1. If necessary, rotation to occiput anterior is performed before
traction is applied.
CLASSIFICATION OF FORCEPS DELIVERY ACCORDING TO
STATION AND ROTATION
OUTLET FORCEPS
Criteria:
1. Scalp is visible at the introitus without separating the labia.
2. Fetal skull has reached the pelvic floor.
3. Sagittal suture is anteroposterior diameter or right or left occiput
anterior or posterior position.
4. Fetal head is at or on perineum. 2. Gentle, intermittent, horizontal traction is exerted until the
5. Rotation does not exceed 45 degrees. perineum begins to bulge.
3. As the vulva is distended by the occiput, an episiotomy may be
LOW FORCEPS performed in indicated.
Criteria:
1. Leading point of fetal skull is at station greater than or equal to station
4. Additional horizontal traction is applied, and the handles are
+2 and not yet on the pelvic floor, and: gradually elevated, eventually pointing almost directly upward.
2. Rotation is 45 degrees or less or 5. During the birth of the head, traction should be intermittent, and
3. Rotation is greater than 45 degrees only with each uterine contraction.
6. Forceps may be removed, and delivery completed by Ritgen
MIDFORCEPS maneuver (perineal support.
Criteria: Station is between 0 and +2
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DYSTOCIA
ABORTION
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ECTOPIC PREGNANCY OUT PATIENT GLUCOSE TARGETS FOR GDM
Implantation of the blastocyst outside the endometrial lining of the Pre-prandial glucose concentrations < 95 mg/dL
uterus 1hr post meal < 140mg/dL
Most common site: ampulla of the fallopian tube
Triad: abdominal pain, vaginal bleeding, amenorrhea 2 hrs post meal < 120mg/dL
Diagnostics:
- hCG POSTPARTUM MANAGEMENT
- Serum progesterone <5 ng/mL 75 grams OGTT at 6 to 12 weeks postpartum
- Culdocentesis reveals non-clotting blood which indicates Recommendations for postpartum follow up are based on 50%
hemoperitoneum from ruptured ectopic pregnancy likelihood of women with GDM developing overt diabetes within
- Transvaginal UTZ 20 years
- Laparoscopy (GOLD STANDARD)
Management: HYPERTENSIVE DISORDERS
- Medical: Methotrexate (folic acid antagonist)
- Surgical: GESTATIONAL HYPERTENSION
Laparoscopy is preferred unless hemodynamically - New onset uncomplicated hypertension during pregnancy when
unstable no evidence of the preeclampsia syndrome was apparent.
Salpingostomy: typically used to remove a small - Systolic BP >140mmHg or Diastolic BP >90mmHg for the first
unruptured pregnancy that is usually < 2 cm in length time in pregnancy.
and located in the distal third of the fallopian tube - No proteinuria
(CONSERVATIVE) - BP returns to normal/resolves before 12 weeks postpartum
Salpingectomy: may be used for both ruptured and
unruptured ectopic pregnancies (RADICAL) PREECLAMPSIA
GESTATIONAL DIABETES
IF AVERAGE RISK, screening done at 24-28 weeks AOG
IF HIGH RISK, screening is done as early as feasible
Severe obesity
Strong family history of type 2 DM
Previous history of GDM, glucosuria, impaired glucose
metabolism
ECLAMPSIA
- Onset of convulsions in a woman with preeclampsia that cannot
be attributed to other causes
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DOC for urgent control of severe hypertension: Hydralazine UTERINE FIBROIDS / LEIOMYOMA
- Max dose: 20 mg IV - Most common neoplasm in women
DOC for maintenance: Methyldopa Types:
DOC for prevention of eclampsia: Magnesium Sulfate 1. Submucous
- Loading dose: 4 g SIVP, 5 g on each buttocks 2. Subseous
- Maintenance dose: 5 g on alternating buttocks q6 x 4 doses 3. Intramural (most common)
- Therapeutic level of MgSO4: 4-7 mEq/L 4. Intraligamentary
10 meq/L: Patellar reflexes disappears Risk Factors:
12 meq/L: Respiratory paralysis 1. Increasing age
>12 meq/L: Respiratory arrest 2. Early menarche
- Antidote: Calcium gluconate 3. Low parity
4. Tamoxifen use
Hypertensive Work-up: 5. Obesity
CBC-PC: sudden decrease in hemoglobin and hematocrit may Signs and Symptoms:
indicate hemolysis; to determine presence of thrombocytopenia 1. Usually asymptomatic
(for the diagnosis of HELLP Syndrome) 2. Abnormal bleeding, usually intermenstrual spotting
Liver enzymes (AST, ALT): for the diagnosis of HELLP Differentials:
Syndrome 1. Pregnancy
LDH: if elevated, may indicate hemolysis 2. Adenomyosis
Bilirubin: if elevated, may indicate hemolysis 3. Ovarian neoplasm
BUN and Creatinine: if elevated, may indicate severe Diagnostics: Ultrasound
preeclampsia Management:
Urinalysis: to determine presence of proteinuria 1. Observation for small, asymptomatic myoma
Serum Na, K, Cl, Mg, Ca, uric acid 2. Myomectomy or hysterectomy depending on the age,
parity, and future reproductive plans
FIGO CLASSIFICATION SYSTEM (PALM-COEIN) FOR CAUSES 3. Medical: GnRH agonists, Danazol, aromatase inhibitors,
OF ABNORMAL UTERINE BLEEDING IN NONGRAVID WOMEN medroxyprogesterone acetate
OF REPRODUCTIVE AGE
OVARIAN NEW GROWTH
Functional Cysts:
- Corpus luteum cyst
- Theca lutein cyst
- Follicular cyst
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CAUSES OF FEMALE PELVIC PAIN TRICHOMONAS, MONILIASIS, GRAM STAINING
1. Torsion 1. Prepare materials: cotton-tipped applicator, 3 glass slides,
2. Pelvic inflammatory disease fixative (NSS), gloves, KY jelly
3. Ovarian new growth 2. Introduce self, explain the procedure, ask for OB score, LNMP,
4. Appendicitis history of D&C
5. Endometriosis 3. Place in dorsal lithotomy position, drape the patient, focus the
6. Adenomyosis droplight
7. Acute Appendicitis 4. Wear gloves
5. Wet the vaginal speculum with PNSS
PAP SMEAR 6. Push the posterior vaginal wall with an index finger
used to obtain cells from the cervix for cervical cytology screening 7. Insert speculum obliquely about 45 degrees, then downward
8. Open the speculum and look for cervix, then lock
When to start cervical cancer screening? 9. Get cotton pledget and collect three specimens from the
Age 18 or once sexually active discharge of the cervix
NOT later than 21 10. Prepare 3 slides:
3 years after onset of vaginal intercourse - Trichomonas: NSS
- Moniliasis: KOH
No previous screening, positive cervical cancer history, DES
- Gram stain: Crystal violet, iodine, alcohol, safranin
exposure, positive HIV
Diagnostic Cues for Sexually Transmitted Infections
Patient Preparation:
Cue STI Agent
Refrain from using tampons, birth-control foams, jellies or other Clue Cells Polymicrobial
vaginal creams for 2-3 days before the test.
Fishy odor after Bacterial Vaginosis usually Gardnerella
No need to douche for 2-3 days before the test. Whiff Test vaginalis
No sexual intercourse for 2 days before the test. Granuloma Klebsiella
The best time is at least 5 days after menstrual period stops. Donovan Bodies
Inguinale granulomatis
School of Fish Chancroid Hemophilus ducreyi
Procedure: Intracellular Neiserria
1. Prepare materials: 3 cotton-tipped applicator, 1 glass slide, Gonorrhea
diplococci gonorrheae
fixative (95% ethyl alcohol), gloves, KY jelly
MENOPAUSE
2. Introduce self, explain procedure, ask for OB score, LNMP,
history of D&C - the time when there has been no menstrual period for 12
3. Place in dorsal lithotomy position, drape the patient, focus the consecutive months
droplight - During this period, LH and FSH levels gradually rise because of
4. Wear gloves diminished estrogen production. The fall in estradiol levels
5. Wet the vaginal speculum with PNSS leads to hot flashes, mood changes, insomnia, depression,
6. Push the posterior vaginal wall with an index finger osteoporosis, and vaginal atrophy
7. Insert speculum obliquely about 45 degrees, then downward - Average age: 48 years old (Philippines)
8. Open the speculum and look for cervix, then lock
9. Get cotton pledgets and take specimen from the endocervix,
- Types: Natural or Induced
swab in a Z manner over the 1/3 of the glass slide. Throw the
use cotton pledget.
10. Another cotton pledget for the ectocervix, swab again over the
middle third of the glass slide. Throw the use cotton pledget.
11. Another cotton pledget for lateral vaginal wall, swab again over
the last third of the glass slide. Throw the use cotton pledget.
12. Place the slide with specimen in a fixative
13. Do IE after speculum exam.
14. Wash hands.
15. Complete the request, then send to the laboratory.
Interpretation:
Superficial Estrogen Reproductive
Intermediate Progesterone Secretory
Parabasal Androgen Menopause Management:
1. Hormonal Replacement Therapy: Estrogen + Progestogen
2. Selective Estrogen Receptor Modulators (SERMS):
Raloxifene, Droloxifene, Tamoxifen
3. Tibolone: has SERM-like property
4. Others: Calcitonin, Intermittent PTH
5. Bisphosphonates: Alendronate, Zolendronate
HPV VACCINE 6. Calcium, Vitamin D
Gardasil (Merck) Cervarix (GlaxoSmithKline) 7. Exercise
Quadrivalent Bivalent
Against HPV types 6, 11, 16 Against HPV types 16 and 18 Note: There are also QUESTIONS on
and 18 ETHICAL CONSIDERATIONS in the practice of OB-GYN
Intramuscular Intramuscular Examples: Autonomy, Confidentiality, Principle of Double Effect
0-, 2-, 6-month schedule 0-,1-,6-month schedule
HPV Types 16 and 18: high risk; can cause cervical cancer
HPV Types 6 and 11: low risk; can cause genital warts Read at your own risk.
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