Obs - ALSO

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dohertys
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131324
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Obs - ALSO
Updated:
2013-01-22 22:12:53
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ALSO course
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ALSO course
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  1. ALSO Lectures
  2. Misoprostol (off-label) dose for incomplete or missed abortion
    • 600 mcg PO or 600-800 mcg PV x 1
    • fewer GI Sx with PV dose
  3. RF's for Ectopic
    • Hx previous ectopic
    • Hx tubal surgery
    • Hx tubal infections
    • Progestin-only contraception
    • Contraceptive IUD
    • In utero DES exposure
    • *may occur in women with no risk factors (obviously)!
  4. Dx of Ectopic
    • Failure of B-hCG to double in 48-72 hours
    • Low serum progesterone
    • TVUS - IUP rules out ectopic
    • No gestational sac + B-hCG > 1800 = highly suggestive of ectopic
    • Gestational sac outside ousters confirms ectopic
    • Gold standard = laparoscopy
  5. Criteria for selecting surgery for ectopic
    • -unstable vitals or hemoperitoneum
    • -uncertain Dx
    • -advanced ectopic pregnancy
    • -unreliable follow-up
    • -C/I to expectant or MTX
  6. Criteria for medical mgmt of ectopic
    • -stable vitals, few Sx
    • -no C/I to drug
    • -unruptured
    • -absence of embryonic heart activity
    • -ectopic mass ≤ 4 cm
    • -starting B-hCG levels < 5,000 - 10,000 mIU/ml
  7. Rh dose for miscarriage in 1st trimester
    50mcg Rhogam for negative women
  8. What should B-hCG do in normal IUP over 48h?
    double in normal IUP
  9. What should B-hCG do in ectopic pregnancy over 48h?
    Stay same or small increase/decrease in ectopic
  10. What should B-hCG do in Spontaneous abortion over 48h?
    Decrease more than 25% in SA
  11. What does progesterone level tell you in 1st term bleeding?
    • < 5 ng/mL = strongly suggestive of SA/Ectopic
    • > 5 ng/mL = strongly associated with live IUP
  12. What should TVUS show @ 3-4 weeks?
    decidual thickening
  13. TVUS @ 4-5 wks?
    If B-hCG level > 1500-2000, then must see a gestational sac
  14. TVUS @ 5-6 wks?
    see fetal cardiac activity
  15. How do you determine GA (menstrual age) by TVUS in 1st term?
    CRL (cm) + 6.5 = age in weeks (menstrual age)
  16. What is float test?
    If passing clots, put then in normal saline - look for float/folliage = chorionic villi
  17. What is a subchorionic hemorrhage?
    A bleed between placenta and uterus (if in 1st trimester)
  18. What is a subchorionic hemorrhage in term 2 and 3 called?
    Abruption
  19. What is the chance of pregnancy loss with PV bleeding?
    50%, but if FHR present then reassuring
  20. What is a heterotropic pregnancy?
    Ectopic + IUP
  21. 3 management choices for incomplete abortion?
    • Surgical (D&C or manual vacuum aspiration)
    • Medical (misoprostol)
    • Expectant
  22. What are considerations for management of incomplete/missed abortions?
    • Incomplete - med and expectant
    • Missed - med is better than expectant
    • Misoprostol - increases bleeding but less pain than surgery
    • Expectant - more outpatient visits
    • Surgery - more trauma, more infection than misoprostol
  23. What is the mechanism of injury in ectopic?
    ECtopic outgrows its blood supply, low blood flow, fetus dies, erodes through tube, intraperitoneal bleed, sepsis/death
  24. When to choose surgical mgmt for ectopic?
    Unstable, uncertain Dx, advanced GA, unreliable to follow up, C/I to meds/expectant
  25. When to choose medical mgmt for ectopic?
    • stable, few Sx
    • No contraindications to meds
    • Unruptured, no FHR, ≤4cm, BhCG ≤4cm
  26. What is medical mgmt of Ectopic?
    • MTX 1mg/kg or 50mg/m2 IM
    • then serum BhCG @ 4, 7days until < 5
  27. Criteria for expectant mgmt of ectopic?
    • no bleeding/pain
    • reliable
    • no rupture
    • <3cm or not found on US
    • NO FHR
  28. Incidence of Ectopics
    >1% of pregnancies
  29. What is a complete hydatidiform mole?
    46XX - no fetus, placenta proliferates
  30. What is a partial hydatidiform mole?
    69XXY
  31. What is recurrent hydatidiform mole?
    Metastatic choriocarcinoma
  32. MGMT of GTD?
    • Prompt removal (D&C)
    • Serial B-hCG's
    • Contraception x 1yr (to allow you to follow B-hCG)
    • Recurrs in 20% - then need MTX
  33. What is an important mgmt consideration for T1 bleeding?
    Rh status - if -ive, give 50mcg Rhogam
  34. When to Rx blood pressure actuely?
    If bp > 160/ >105-110
  35. What to use to Rx acute bp in pregnancy?
    Labetolol, Nifedipine XL, Hydralazine
  36. Labetolol dose?
    • Labetolol - 20mg IV bolus, then if still high after 10 min
    • 20-80mg IV q 30min
    • 300mg max
  37. Hydralazine dose?
    5-10mg IV q20min, 20mg max
  38. Nifedipine XL dose?
    5-10mg PO q30min
  39. Preferred dose of anti-convulsant in severe preeclampsia?
    MgSO4 4-6g IV over 15-20min, then 2g/h IV
  40. Main concern with MgSO4?
    May affect renal fxn. Don't send Mg level as will be panic high, unless Pt has oliguria or high Cr
  41. Antidote if MgSO4 toxicity?
    Calcium gluconate 1g IV over 3min

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