Procedure Ready: Ob/Gyn

High yield resources and tips for your Ob/Gyn clerkship. Youtube Playlist: http://bit.ly/pimped-ob Books: Netters Obstetrics and Gynecology by Beckmann Apps: Pimped App – Clinical questions to expect in the OR and on the wards Uptodate Epocrates GoodRx LactMed – medications safe in breastfeeding ASCCP: Cervical cancer screening CDC STI guidelines ACOG app/website OB Wheel or dating Tips and Tricks: Be Proactive—talk to students who just finished the rotation about ways to be helpful and the day to day logistics. Expectations: Ask for them to be set at the beginning. Clarify as needed. Be Self-sufficient, but ask for help when appropriate Before leaving for the day, ask when you should come in to round, who to pre-round on and where to meet. Once or twice a week ask for feedback when everyone has a down moment. Labor and Delivery: Gs & Ps aka Gravity and Parity. Primes, multips Gestational age Preterm vs term

The OB One-Liner: “This is a _ yr old G_ P_ @_ wks GA here for ____.” Ex: This is a 34yo G3P2002 @ 38wks3days GA here for contractions Triage: 4 essential questions to ask every pregnant woman in triage Contractions, leaking fluid, vaginal bleeding, fetal movement What is labor? Cervical change and contractions Evaluate for ROM: Pooling, nitrazine (pH), ferning. Vaginal bleeding—when do we care? 2nd or 3rd trimester worry about placenta: abruption, previa, vasa previa DFM: NSTs, BPPs, Kick counts

Cardinal movements of labor: engagement, descent, flexion, internal rotation, extension, external rotation and expulsion Complete dilation, now station: Labor down vs push 2nd Stage of labor: Pushing Offer to help with maternal positioning—holding ankle/leg Delivery—downward traction on head, thumbs to nose, anterior shoulder, posterior shoulder, body. Skin to skin. Delayed cord clamping. 3rd stage placenta: Active management, Pitocin, gentle cord traction. 3 signs of placental detachment Bleeding: Atony, meds Lacerations: degree, repair Postpartum: Fundal tenderness, lochia, voiding, BMC.

Why? Scheduled: Repeat cesarean, hx of uterine surgery, abnormal placentation (placenta previa, vasa previa, accrete, etc) malpresentation (not cephalic), multiple gestation In labor: arrest of dilation, arrest of descent, nonreassuring fetal heart tones, elective Anatomy: Layers of anterior abdominal wall: skin, subcutaneous tissue, superficial fascia (Campers, scarpa’s), external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose and areolar tissue, and peritoneum. Nerves, blood vessels, and lymphatics are present throughout. Now you’re at the uterus — or should be. Clear the surgical field, take down adhesions, bladder flap if needed. Hysterotomy — lower uterine segment, lateral uterine vessels to avoid Delivery baby — delay cord clamp, placenta Likely lots of bleeding — same atony meds as vaginal delivery Clean inside of uterus to remove all membranes etc. Possibly exteriorize uterus to see better — depends on scaring How can you be helpful — visualization! Bladder blade back in, suction or clean with lap between when surgeon placing sutures. Two layers to hysterotomy if they might ever want to labor again or if needed for hemostasis. Clean up the abdomen–irrigation vs moist laps vs suction Now to close: Peritoneium — either way, close or not– no evidence either way Muscle– don’t close, evidence that closing it can cause hematoma Fascia–Close! Closing Fascia: Nerves at the lateral edges of the fascial incision are ilioingiunal, iliohypogastric Subcutaneous fat — if >2cm depth, close to reduce risk of seroma/hematoma/infection Skin closure — stables, suture, absorbable stables    

Hypertension in Pregnancy — One large spectrum Mild range: 140/90 Severe range 160/110 CHTN → SIPE gHTN → Pre-E BP meds: Methyldopa, labetalol, hydralazine, nifedipine Severe features: BPs Neurologic symptoms Lab findings: HELLP Hemolysis, Elevated Liver (enzymes), Low Platelets Eclampsia — Seizures

Review anatomy– you’ll be able to see well! Pimped- Youtube Channel videos for laparoscopic anatomy What case are you doing and why? Review common indications, steps to procedure and potential risks/complications Saying hi to the patient first Being helpful setting up — yellowfins or stirrups for lithotomy Scrubbing in — ask to grab your gown/gloves for the scrub, open carefully or get help if unsure Abx: If entering uterus or vagina ie hyst Prep: infection prevention with chloraprep or something EtOH based, needs to evaporate before draping or risk fire! Vaginal prep — betadine or chlorhexidine Then everyone scrubs Let resident/attending drape unless asked. You may be asked to help with foley/manipulator Uterine manipulators: Many sizes/shapes/types Vagina is dirty– can’t go from vagina to abdomen Abdomen: Entry: Typically in umbilicus or just above. Can use Palmer’s Point if needed. Direct visualization with Hassan Visiport Veres needle Insufflate with CO2 Port placement: Typically middle ⅓ of distance between ASIS and umbilicus. Avoid obvious superficial vessels and inferior epigastric –watch from below Common procedures: Dx LSC– endometriosis, adhesions Tubal ligation or bilateral salpingectomy Cystectomy BSO Hysterectomy Closing ports: Close fascia on ports >5mm due to increased risk of hernia Post-op checks: Many LSC cases are same-day, meaning patients go home -Nausea/vomiting, eating/drinking, voiding, passing flatus, ambulating -UOP, BPs,

What approach: Abdominal, laparoscopic, vaginal or combination Taking or leaving the tubes and ovaries? Tubes: What benefit do they provide? Risk? Ovaries: What benefit do ovaries provide? What about after menopause? Still have benefit for bones and cardiovascular health. 65yr old cut-off If it’s laparoscopic–listen to the LSC podcast for more details on the approach Let’s talk about important steps: The round ligament: What artery runs inside the round? Sampson’s. What structure conceals the blood flow to the ovary? The IP ligament (formerly the suspensory ligament of the ovary). The artery comes from the aorta, so if this is transected before it is fully sealed, it can hemorrhage while retracting back into the retroperitoneum. Badness! What are the four levels at which the ureter is injured during hysterectomy? 1- At the pelvic brim, 2- medial to the IP ligament, 3- as it passes under the uterine artery (water under the bridge) and 4- lateral to the vaginal cuff closure. Ligate and transect the uterine arteries–the uterus should blanch white. Colpotomy– disconnecting uterus from vagina Close vaginal cuff if total hyst

Resources: https://www.bedsider.org/methods   Table: http://www.womenscommunityclinic.org/wp-content/uploads/Bedsider-Birth-Control-Effectiveness-Poster.jpg Spanish: http://s3.amazonaws.com/providers/images/images/000/000/032/center/Spanish_tiers_of_effectiveness.png?1464661802

Nonreassuring fetal heart tracing Category 2-remote from delivery Minimal/absent variability is most significant predictor of fetal acidemia Category 3 any time is emergent deliver Failed IOL Many different definitions: Most commonly 12-24hrs ruptured membranes on pitocin without active labor Arrest of dilation Can only meet criteria once in active labor 6cm or greater Do you know if her contractions are adequate? IUPC with MVUs>200-250 If the contractions are adequate, no change over 4hrs If contractions are inadequate or no IUPC, no change over 6hrs Arrest of descent Prime with epidural 3hrs Prime without epidural-2hrs Mutlip with epidural 2hrs Multip without epidural 1hr Cord prolapse -Emergency! Malpresentation -Breech, transverse, compound

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

Causes (Four T’s): Tone: Atony Pitocin Misoprostol: CI-allergy, SI-transient hyperthermia Methergine: CI-HTN, SE-HTN Hemabate: CI-asthma. SE-diarrhea Tamponade: bakri/utah balloons Trauma: Lacerations Tissue: Retained POC (placenta or membranes) Thrombin: Coagulopathy   Other: Involution

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

Hysteroscopy = looking inside the uterus with a scope Steps: Dilate the cervix Distend the uterus with fluid 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.

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.

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”  

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

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.

Cancer Screening Cervical: Age 21-65 Cytology q3yrs, co-test q5 if normal. ASCCP guidelines (there is an app! Or PDF: http://www.asccp.org/Assets/51b17a58-7af9-4667-879a-3ff48472d6dc/635912165077730000/asccp-management-guidelines-august-2014-pdf ) Breast: ACOG: 40-75 annual mammogram Colon: Colonoscopy, FOBT, FIT. Begin at age 50. If first degree relative with colon cancer begin screening at age 40 or 10yrs prior to youngest diagnosis, whichever is younger. Lung: 55-80 with 30pack-year hx, annual low-dose CT 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

Definition: Failure to deliver fetal shoulders with normal downward traction  Why we care: Baby hypoxia, brachial plexus injuries, maternal injuries Risk factors:  DM, excessive weight gain in pregnancy, S>D, Large baby Hx of shoulder dystocia (~10-15% recurrence) Turtling while pushing  Prevention  No real prevention as SD is very hard to predict  Offer cesarean delivery if EFW is >5000g and no DM, or >4500g and any type of DM What do to:  Step back. If comfortable, can help minimize family interference. Calmly explain what is happening and what the docs are doing.  Offer to be the Timekeeper. Write down times and what is happening. Announce every 2 minutes.  What you’ll see:  Prep: Hypothesize shoulder orientation for suprapubic pressure, place stool  Announce problem- call for help Maneuvers - McRobers, suprapubic Posterior arm Rotational: Wood’s screw, Rubin Gaskins- all 4s Episiotomy Zavanelli 

Indications:  Post-dates (42+wks)  Late Term (41+ wks) Elective 39+wks  Diabetes Hypertension  Many more - check out ACOG Medically indicated delivery  39week induction ARRIVE Trial - Multicenter RCT showing benefit to 39wk IOL over expectant management to ~41wks  Included  Primips  No medical indications for IOL prior to 40+5   Results  IOL group had LOWER c-section rate than expectant group  Neonatal composite outcome had a trend (not statistically significant) toward lower neonatal compilations in IOL group  Conclusion IOL at 39wks is as safe as expectant management without increased risks Many pregnant people are now offered a 39wk IOL rather than waiting for spontaneous labor  The IOL Process:    Evaluate and Prep: Full H&P Ultrasound for position - Vertex VE for cervical exam: dilation/effacement/Station, also position and consistency  Calculate Bishops Score → help determine mode of IOL Options for IOL: if biship score <8 for prime or <6 for multip, ripen first!  Mechanical cervical ripening (balloon) Chemical cervical ripening (misoprostol or cervidil)  Best yet--both!    Contractions (pitocin)  Prime: Pitocin alone if Biship 8 or higher Mulitp: Pitocin alone if bishop 6 or higher    Augmentation: AROM    Failed IOL Failure to reach active labor after 18+hrs ruptured on pitocin (definition varies 12-24hrs ruptured on pitocin)  If reaches active labor (6+cm), no longer failed IOL, now arrest of dil...