Cancer Screening and Vaccinations (HCM)
Ob/Gyn

 
 
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Cancer Screening

Vaccinations

  • HPV: 3 dose series age 12-26
  • Influenza: annual
  • Pneumovax: 1 dose and 1 booster any age if risk factors. After age 65 if no risk factors
  • Shingles: 2 dose age 50+
  • Hep B: initial vaccination in youth, vaccination for anyone non-immune
  • MMR: if not immune
  • Varicella: if not immune
  • Tdap: Booster at 10yrs, new parents

STIs
Ob/Gyn

 
 
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Swab/Urine

  • Chlamydia: usually asymptomatic. Screen routinely. Can cause infertility/PID and Fitz-hugh-curtis. Treat with Azithro x1
  • Gonorrhea: often asymptomatic. Screen routinely. Can cause infertility/PID. Treat with Ceftriaxone and Azithromycin
  • Trich: frothy/watery discharge. “Strawberry cervix” Can see trich moving on wet mount. Treat Flagyl 2g PO once.
  • HPV: Cervical dysplasia/cancer and Genital warts. Topical treatments as needed.

Serum

  • Syphilis: Painless chancre followed by latent, then secondary with palmar/plantar rash. If unsure stage, treat as if latent, PCN IM x3
  • HIV: Universal screening. PREP if high risk. Referral to ID and counseling if positive.
  • Hep B: Treatable, not curable. Routine serum screening.

No Routine Screening, diagnose if lesion

  • HSV: Antivirals as needed for outbreaks, can prophylax if frequent outbreaks/immunosuppressed. Valacyclovir or acyclovir are most common.

Before Your First: Colposcopy and LEEP
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Why: ASCCP guidelines (there is an app! Or PDF)

Cervical dysplasia — caused by HPV

CIN I–CIN3 is a progression

Risk factors: Smoking, other STIs including HIV, immunodeficiency

 

Histology: Increased Nuclear: cytoplasmic ratio when abnormal

Acetic Acid: exact mechanism unknown, the higher N:C ratio cells (aka abnormal cells) reflect more light and appear white.

Lugols: Iodine rich-reacts with glycogen in normal squamous cells so they appear dark.  Non-staining cells are abnormal.

 

HPV — changes

Colpo:

Increased vascularity, punctations, mosaicism, surface contour changes

 

LEEP:

Stain abnormality and know where abnormal biopsy was taken

Single pass is ideal–tag a side for orientation

+/- Top Hat depending on ECC result

 

CKC:

Higher up in cervical canal, but more complications

No electricity– okay if pregnant

Return OB Visits
Ob/Gyn

 
 
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Every visit:

  • Doptones, fundal height, vitals
  • Four question: Vaginal bleeding, contractions, leaking fluid, fetal movement

By Weeks:

  • 20wks – get and review anatomy US
  • 24wks – order glucola, cbc (check for anemia), discuss normal growing pains
  • 28wks – Tdap and Rhogam if needed, discuss kick counts
  • 32wks – Discuss BCM, sign tubal papers if needed, discuss TOLAC if needed
  • 36wks – GBS screening, birth expectations, US for position
  • 38-40wks – VE, “sweep membranes”

 

First Prenatal Visit
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  • Planned/Desired
  • Options counseling if needed
  • Exam/pelvic/pap
  • Ultrasound for dating
  • Screening options: QUAD, Sequential, NIPS, invasive testing
  • Pregnancy guidelines
  • Weight:
    • BMI under 18.5 should gain 28–40 pounds.
    • Normal-weight women (BMI, 18.5–24.9) should aim for 25–35
    • Overweight women (BMI, 25–29.9) should aim for 15–25
    • Obese women (BMI, 30 or more) should gain only 11–20
  • Food: Avoid unpasteurized dairy, large fish (swordfish, shark, king mackerel, tilefish, bigeye tuna etc), uncooked meat/seafood, uncooked deli meat, EtOH
  • Drugs: Nothing unless cleared by MD. Tylenol okay if needed, PNV, Colace, FeSO4. NO NSAIDs!
  • Exercise: Nothing that could leave a bruise on your belly! Moderate exercise is great.

Before Your First: Hysteroscopy
Ob/Gyn

 
 
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Hysteroscopy = looking inside the uterus with a scope

Steps:

  1. Dilate the cervix
  2. Distend the uterus with fluid
  3. Look around, identify pathology, identify tubal ostia, remove pathology if using an operative scope or Myosure or another resectoscope.

Feared complication: Hyponatremia from excessive hypotonic fluid absorption.

Peripartum Fevers
Ob/Gyn

 
 
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Intrapartum

Differential diagnosis for Temp >38.0C

  • Epidural fever (transient), DVT/PE (if prolonged IOL or limited mobility), UTI, Intraamniotic infection (with or without ROM), etc

 

Chorioamnionitis aka IAI aka Triple-I (intrapartum intraamniotic Infection)

  • One temp >39.0C
  • One temp 38.0C-39.0C AND one or more risk factors
  • Two temps >38.0C 30+ mins apart

Tx: the standard is Ampicillin/Gentamycin until delivery. Tylenol prn temp>38C, IVF for maternal/fetal tachycardia, cooling blanket if needed to decrease temp.

 

If mild PCN allergy: Ancef/Gent

If severe PCN allergy: gent/clinda or gent/vanc

 

If vaginal delivery: No evidence that continued abx postpartum provide benefit.

 

If c-section: Add clindamycin to Amp/Gent.

Continue at least 1 dose postpartum. Clinical judgment on when to d/c. Some do 1 dose, some 24hrs afebrile, until clinical improvement, etc.

 

Postpartum

Wind – PNA, atelectasis, URI

Womb – Endomyometritis — Gent/Clinda x 24hrs afebrile

Wound – Superficial wound infection, cellulitis — eval for collection, probe wound/fascia if able

Water – UTI, Pyelo — get UA

Walking – DVT/PE

Weening – Engorgement or mastitis

Wonder drugs

Postpartum Hemorrhage
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Causes (Four T’s):

  1. Tone: Atony
    1. Pitocin
    2. Misoprostol: CI-allergy, SI-transient hyperthermia
    3. Methergine: CI-HTN, SE-HTN
    4. Hemabate: CI-asthma. SE-diarrhea
    5. Tamponade: bakri/utah balloons
  2. Trauma: Lacerations
  3. Tissue: Retained POC (placenta or membranes)
  4. Thrombin: Coagulopathy  
  5. Other: Involution

Who’s that collar?
Ob/Gyn

 
 
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Hello from Addison and Lundy.

Preterm Labor and PPROM
Ob/Gyn

 
 
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ACOG Practice bulletin: # 171

PTL or TPTL:  Preterm <37wks, cervical change

Evaluation:

SSE first: Collect GC/CT cultures, FFN (no gel, blood or semen), GBS, eval for rupture if needed

SVE:

Cervical change–can dilation or effacement changes

FFN: Fetal fibronectin

If tPTL:

  • Magnesium for neuroprotection if <32wks, decrease CP rates
  • Betamethasone for fetal lung development
  • PCN
  • Tocolysis for steroid window (48hrs) if <34wks, questionable if 34-36+6. Indocin if <32 wks, Nifidipine if 32+wks
  • IV fluids
  • NICU consult

PPROM: Preterm <37wks, Ruptured membranes

SSE: Confirm rupture with Pooling, nitrazine ferning. Collect GC/CT and GBS.

If PPROM: Delivery at 34wks or at diagnosis if chorio or 34+wks

  • Latency antibiotics: Erythromycin/Azithromycin, Ampicillin x 2 days, PO Erythro/Amoxicillin x 5 days
  • Magnesium for neuroprotection if <32wks, decrease CP rates
  • Betamethasone for fetal lung development
  • PCN
  • NO Tocolysis
  • NICU consult