1
Q
Sexual history
A
- age with first partner
- # of partners in the past
- # partners now
- male/female/both
- anal/vaginal/oral
- unprotected sex
- sexual abuse
- STDs
- HIV
2
Q
Gyne history
A
Age at menarche LMP Age of menopause Menstrual: -regularity -#days of bleeding -amount of bleeding- # pads -associated symptoms: dysmenhorrhea, bloating, PMS -# days between periods -spotting btwn periods
- contraception
- last PAP
- abnormal PAP
3
Q
Obsterical history
A
pregnancies
# children: living, dead
-pregnancy complications- diabetes, pre-eclampsia, eclapsia, liver, wks of gestation, thyroid disease, infections during pregnancy
-delivery complications- placenta pre via, vasa, abrupt, PROM
-post delivery complications- bleeding, rupture
-problems of with baby
-# abortions: at which weeks, spontaneous vs planned
4
Q
Abortion history
A
- social history
- status of relationships with child’s father
- social suport: family, friends, boyfriend, do they know? what support are they providing
- employment
- finances
- education
- how does she feel about pregnancy?
- how is she coping?
- ready to raise a child?
- Depression screening: MSIGECAPS
5
Q
Abortion counseling
A
- difficult situation
- encourage engaging social support, visit with both patient and support person
- health while pregnant: abstinence from alcohol, smoking, drugs, healthy eating, activity
- abortion: usually decision made before 16 weeks, referral to gynecologist if she wants
- arrange for follow up
6
Q
OCP History
A
- why does pt want OCP?
- previous forms of contraception? why was it stopped?
- sexually active?
- number of partners?
- current contraception
- pregnancy?
- LMP?
- Pregnancy hx
- Gyne hx: first period, menstrual history, STD, PID, fibroids, PAP smear
- Contraindications to OCP: thromoembolic disease, heart problems, cancer, liver disease. migraines
- Basic info: PMHx, meds, allergies, smoking, alcohol, drugs, hx of breast cancer, FMhx of breast cancer
- ROS
7
Q
Absolute Contraindications to OCP
A
- current pregnancy
- undiagnosed vaginal bleeding
- active cardiovascular/thromboembolic disease
- hx of breast cancer, estrogen dependent tumours
- impaired liver fxn
- age>35 and smoking
8
Q
Relative contraindications
A
- smoker
- diabetes
- migraines
- fibroids
9
Q
Mechanism of action of OCP
A
- prevents ovulation by interfering with hormone signalling: atrophic endometrium, change in cervical mucous
- estrogen and progesterone or just progesterone pills
21 or 28 day pills
- Depo injections Q3 months
- IUD
10
Q
Benefits of OCP
ABCDE
A
- less anemia, acne
- less benign crest disease and cyst
- less cancer (ovarian), regular cycles, inc cervical mucous to dec STDs
- dec dysmenorrhea
- decrease ectopic pregnancy
- 98-99.5% effective
11
Q
Disadvantages of OCP
A
- inc risk DVT (with smoking)
- may stimulate estrogen receptor positive breast cancer
- still need barrier methods to prevent STDs
12
Q
Directions for OCP
A
- start OCP, 1st sunday of next period
- put in obvious place, take same time everyday
- if miss 1 day, take 2 next day. if miss 2 days, take 2 next 2 days, use alternative method until next period.
- follow up
13
Q
History for vaginal discharge
A
- onset, chronology, color, consistency, odor, timing (related to menses)
- associated symptoms: abdo pain, burning, itching, dyspareunia, disuria, urgency, frequency
- things that make it better or worse
- recent use of antibiotics
- sexual history: #partners, type of contraception, possibility of pregnancy, hx of STD
- obstetric hx
- gyne hx: menstrual pattern, PAP smears
Basic info: PMHx, Meds (OCP, antibiotics), allergies, PFHx
14
Q
Differential diagnosis for vaginal discharge
A
- physiological: midcycle, increased estrogen states
- infectious: candidiasis, bacterial vaginosis, trichomonas, chlomydia, gonorrhea, bartholinitis, PID
- neoplastic: vaginal intraepithelial neoplasia, vaginal SCC, cervical carcinoma
- other: allergic/irritative vaginitis, foreign body, atrophic vaginitis
15
Q
Investigations for Vaginal discharge
- cadidiasis
- bacterial vaginosis
- tricomonas
A
- speculum exam
- swab and culture
- saline slide microscopy
- KOH whiff test
- cadidiasis- white, lumpy
- bacterial vaginosis: grey, thin, clue cells, fishy door
- trichomonas: frothy yellow/gray/green discharge, motile tricomonads seen under microscope
16
Q
Management of vaginal discharge
A
- cadidiasis: canesten (clotrimazole) or miconazole creamx7 days
- bacterial vaginosis and trichomonas: metronidazole 500 mg PO BID x 7 days
17
Q
History for 24 yo with LLQ abdo pain with IUD, has signs of peritoneal irritation
A
- onset, PQRST of pain, relation to periods/intercourse
- sexual history: partners, men/women/both, protection used, contraception used before
- Gyne history: first period, menstrual history, LMP, STD, PID, fibroids, PAP smear
- pregnancy history
- fever
- N/V/D, blood in stools, urinary freq/urgency/dysuria, trauma
18
Q
Ddx for LLQ abdo pain with IUD
A
- uterine perf with IUD
- PID
- tubo-ovarian abscess
- ovarian cyst w/torsion
- ectopic pregnancy
- GI: gastro, IBD, intestinal obstruction, appy
19
Q
Physical for LLQ abdo pain with IUD
A
- vitals
- abdominal exam: inspection- symmetry, distension, bruising, auscultation, percussion, palpation
20
Q
Investigations for abdo pain with IUD
A
- CBC, lytes, glucose, creat, INR/PTT, BHCG, UA, urine culture
- PAP smear, cervical swab for gono, chlamydia
- Abdo ultrasound
21
Q
Definition of pre-eclampsia, eclampsia
HELLP
A
Pre-eclampsia= pregnancy-induced or worsened HTN
- SBP inc 30 mmgHg
- DBP inc 15 mmHg
- with renal impairment: proteinuria
- /+ non-dependent edema (face, hands) at >20 wks
Eclampsia- pre-eclampsia with CNS involvement (LOC, seizures, hyperreflexia)
Due to imbalance of thromboxanes, prostaglandins
HELLP: complication of pre-eclampsia, hemolysis, elvated liver enzymes, low platelet
22
Q
Criteria for severe pregnancy induced hypertension (PIH/pre-eclampsia)
A
2 of the following BP> 160/110 Resp: pulm edema CVS: CHF Kidney: proteinuria/oliguria, inc creat Abdo: N/V/ RUQ pain, inc LFT Heme: thrombocytopenia, hemolysis Neuro: visual disturbance, hyperreflexia, clonus, headache IUGR
23
Q
Physical exam for pre-eclampsia
A
- vitals
- Resp: for pulm edema
- CVS for CHF
- Abdo: RUQ tenderness
- Neuro: reflexes, clonus
- peripheral edema
24
Q
Investigations for pre-eclampsia
A
CBC, lytes, creat, LDH
liver enzymes, INR/PTT
UA with microscopy
Fetal HR, non-stess test, BPP, doppler flows
25
Management of pre-eclampsia
Daily BP
Daily fetal movement counts at home
Weekly CBC, lytes, creat, liver enzymes, fetal monitoring
Seek medical attention if abdo pain, visual disturbance, persistent headache, drowsy, seizure
Admission if any of the symptoms for MgSO4, and induction of delivery, c/s
If high blood pressure (>160/110), admit for hydrazine or labetalol, or nifedipine
26
History for third trimester vaginal bleeding
- ID, age
- GPA- # born at term, #living
- weeks of gestation
- bleeding: onset, duration, quantity, color and consistency of blood
- contractions
- fetal movt
- last sexual intercourse
- abdominal trauma
-this pregnancy: serology, ultrasounds, prev bleeding, HTN, diabetes,
27
Physical exam for third trimester vaginal bleeding
- no speculum or vaginal exam until US to r/o placenta pre via
- vitals
- fetal monitoring
28
Differential diagnosis for third trimester vaginal bleeding
- placenta previa: placenta covers internal os, most common cause of painless bleeding
- blood show- shedding of cervical mucous plug
- vasa previa: fetal blood from root of vessel of umbilical cord overlying cervical os
- abruptio placenta- separation of placenta from uterine wall (+++ abdo pain)
- uterine rupture, vaginal infection, cervicitis
- blood from bladder, bowel?
29
Investigations for third trimester vaginal bleeding
- CBC, INR/PTT, fibrinogen
- type and cross match, Rh status
- Ultrasound, BPP
- Apt test for fetal hemoglobin
30
History for spontaneous abortion at 6 weeks
- bleeding: onset, duration, clots?
- fever, abdo pain, trauma, weakness/faintness
- this pregnancy: serology, hypertension, diabetes, problems?
- medical visits to this point? investigations done at this point?
- Past obs hx
- Past gyne hx
- PMHx, meds, allergies, smoking, alcohol, drugs
31
Types of abortions
- threatened
- inevitable abortion
- incomplete abortion
- complete abortion
- missed abortion
- threatened abortion: any bleeding/cramping in first 20 wks. 50% will continue to have abortions. (closed cervix)
- inevitable abortion: pain, bleeding, cervix open, but hasn't passed products of conception
- incomplete abortion: part of products of conception passed, cervix open
- complete abortion: uterus empty, bleeding+products passed, cervix open
- missed abortion: as symptomatic, mild bleeding but failure for pregnancy to progress- absence of uterine growth and decreased symptoms of pregnancy
32
Physical exam for incomplete abortion
findings consistent with incomplete abortion
- ruptured membranes
- products of conception passed
- cervix dilated (os open)
33
History of secondary amenorrhea, polycystic ovary syndrome
Gyne history: age at menarche, previous menses, duration, heavy bleeding, headache, visual disturbances
Sexual history- contraception, pregnancy?
Signs of virilization: body hair, acne, muscle bulk, galactorrhea
Hypothyroid/hyperthyroid symptoms?
Exercise?
gain/lost weight?
stress?
34
Investigations for PCOS
- pregnancy test
- TSH, prolactin, testosterone, DHEAS
- FSH, LH (high= ovarian failure, low= hypothalamic dysfunction)
- progesterone challenge (for withdrawal bleed)- if there is withdrawal bleed, indicates anovulation, if no withdrawal bleed- suggests end organ failure or outlet obstruction
- abdo ultrasound
in PCOS: high LH, androgens, ovarian cysts on US
35
Ddx for PCOS (amenorrhea)
```
pregnancy
excessive exercise
stress
weight loss
thyroid dysfunction
prolactinoma
hypopituitarism
```
36
Differential for symmetric IURG
TORCH infections
Chromosomal abnormalities
Familial
37
Differential for asymmetric IUGR
-placental insufficiency: maternal nutrition, smoking, alcohol, drugs, illness during pregnancy, hypertension
38
Causes of neonatal jaundice
| unconjugated
- physiological
- hemolytic: ABO incompatability, sepsis, hereditary spherocytosis, G6PD
- nonhemolytic: breast milk jaundice, breastfeeding jaundice, breakdown of cephalohematoma, sepsis, hypothyroid, filberts, crippler-najjar
39
Causes of conjugated
- bile duct obstruction
| - drug induced
40
Counseling for pregnancy in older women
- ID, planned pregnancy
- status of relationship
- social supports
- social situation- finances, work, ready to have baby
- morning sickness, vaginal bleeding
- mood
-Current pregnancy: LMP, ultrasound dating
Expected delivery date: LMP+7 dates- 3 months
- Menstrual history:
- PObsHx:
- PMHx, PSHx, meds, allergies
- hypertension, diabetes
- smoking, alcohol, drugs, diet, exercise
- FMhx: inherited disorders, heart disease, circulatory problems, renal disease
41
Physical history for new pregnancy
- vitals
- CVS
- Abdo
- Breast exam
- measure uterus size
- doppler fetal heart
- vaginal exam- swab for GC, chlamydia
42
Investigations for new pregnancy
- CBC, lytes, INR/PTT, urea, Cr
- Folate
- UA
- blood group and type
- VDRL and HbSAg
- Rubella
- HIV
43
Investigations for new pregnancy for screening of chromosomal abnormalities
-Triple screen: AFP, BHCG, uE3 at 16 weeks
trisomy 18, trisomy 21
-Amniocentesis at 16 weeks
-chorionic villus sampling at 10-12 weeks
-fetal ultrasound
44
General counselling for pregnant patient
- daily vitamin, milk, healthy diet
- weight gain of 2-3 lbs/mo, total weight gain of 25-30 lbs
- normal activities
- no alcohol, smoking
- for morning sickness: small meals
- common: hemmorhoids, backache, heartburn, vaginal discharge
- F/U Q4 wks until 32 weeks then q2 weeks
- call if any concerns- abdo pain, bleeding, infection
45
Post menopausal bleeding
| Hx
- onset, chronology, amount, vaginal discharge, pain
- abdo pain
- weight loss, fever, night sweats, lymph nodes?
- sexually active? protection?
- post coital bleeding
- rectal bleeding
- easy bleeding/bruising?
- gyne history: age of first period, # days, regular, dysmenorrhea, when did periods stop
- STDs, last PAP smear
- hx of fibroids, polyps, PID, PCOS
- PObsHx, GPA, complications
- PMHx, PSHx, FHx, meds, allergies
46
Ddx for post menopausal bleeding
- malignancy: endometrial cancer
- endometriosis
- fibroids, polyps
- thyroid
- bleeding disorder
47
History for gonnococcal infection
- joint pain (migratory joint pain)
- fever, abdo pain, vaginal discharge, pain with urination, dyspareunia
- hx for other cause of joint pain: arthritis, osteoarthritis, reiter's syndrome, ankylosing spondylitis
```
Gyne hx
Previous STDs, PID
Sexual history, # partners, protection used
PObxHx
PMhx, FHx
```
48
Investigations for STDs, Gonnorrhea
CBC, lytes, urea, Cr, ESR
Blood cultures
cervical swab for gonnorrhea and clamydia
Joint aspiration for microscopy and culture
49
PAP smear results of CINIII/HSIL
| Take history
- vaginal discharge?
- post-coital bleeding?
- pelvic or back pain?
- sexual history, age of 1st intercourse
- # partners
- previous STDs
- previous HPV infection
50
PAP smear schedule
Start q1 year after sexually active
Start at age 21
If normal x3 or if after age 30 then can do q2 years
Stop at age 70, if neg x3 or no abnormalities in past 10 years
51
PAP smear results
CIN-I/LSIL
CIN II-III/ HSIL
CIN-I: repeat in 3 months, many lesions will regress on their own. if +x3 then colposcopy
CIN-II, III: colposcopy
- laser
- LEEP
LMCC
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