General OBGYN Flashcards
(232 cards)
1
Q
Resp changes in pregnancy?
a) RR
b) tidal volume
c) expiratory reserve volume
d) inspiratory reserve volume
e) FRC
f) RV
g) vital capacity
A
a) unchanged
b) increase
c) decrease
d) unchanged
e) decrease (by 20-30%)
f) decrease
g) unchanged
2
Q
Fetal risks of ABx exposure:
a) sulfa drugs
b) nitrofurantoin
c) streptomycin
d) tetracycline
e) amoxicillin
f) chloramphenicol
A
a) in T3 - increased bilirubin, kernicterus, hemolytic anemia, skeletal abnormalities
b) in T3 - affects glutathione reductase activity, hemolytic anemia
c) ototoxicity
d) teeth staining, impaired skeletal growth
e) NEC
f) aplastic anemia
3
Q
Normal umbilical cord arterial blood gas for term infants?
A
pH 7.2-7.34
pCO2 39-62
pO2 10-27
HCO3 18-26
BE -5.5 to -0.1
4
Q
Components of a BPP scan?
A
5
Q
most significant risk factor for postpartum depression?
A
adolescent pregnancy
6
Q
risks of retinoids in pregnancy? (2)
A
- microtia (small ears)
- microophthalmia (small eyes)
7
Q
risk of uterine rupture in TOLACS?
A
of prior c/s
- 1 prior LTCS: 0.47%
- 2 prior LTCS: 1.59%
IOL with TOLAC
- IOL at any GA: 1.5%
- IOL at 40wks or more: 3.2%
Inter-delivery interval:
- < 12 months: 4.8%
- < 15 months: 4.7%
- 18-24 months: 1.9%
Incision type:
- Low vertical incision: 1-2%
- Classical or inverted T incision: 4-9%
No 382 TOLAC
8
Q
factors improving TOLAC success? (10)
A
- previous vaginal delivery = most important predictor
- age <30yrs
- BMI <30
- caucasian
- c/s indication NOT for Dystocia
- spontaneous labor
- Bishop >=6 on arrival
- BW <4000g
- GA < 40wks
- epidural use
No 382 TOLAC
9
Q
factors decreasing TOLAC success?
A
- age >35yrs
- BMI >30
- gestational age >40wks
- preeclampsia
- previous c/s for dystocia, failure to progress or CPD
- IOL requiring cervical ripening
- need for augmentation
- BW >4000g
No 382 TOLAC
10
Q
difference in presentation for clostridium vs GAS?
A
clostridium: TSS without fever
GAS: nec fasc + fever
11
Q
how to deliver brow presentation?
A
c-section
12
Q
considerations for c-section in obese patients?
A
- increased dose of ABx PPx: cefazolin 3G if > 120kg
- consider vertical midline, infra or supraumbilical skin incision
- exposure/traction: e.g. Alexis-O retractor
- longer instruments
- OR table weight cut-offs
- closure of subcut tissues (especially if > 2cm thick)
- increased rate of epidural failure (for c-section in labor)
- increased VTE PPx dosing
- PICO dressing
- devices to assist in patient transfer post-op
- difficult airway if GA needed
13
Q
obesity has the greatest effect on which stage of labor?
A
first stage: increased risk of c-section for first stage arrest
14
Q
when is delivery recommended for obese patients?
A
delivery by 40wks for BMI >40
15
Q
RFs for PET: (table)
a) high risk (7)
b) moderate risk (6)
A
16
Q
recommended fetal surveillance for obese patients?
A
- serial growth: at 28, 32 and 36wks
- weekly BPP starting at 37wks
17
Q
gestational weight gain recommendations based on BMI? (table)
A
18
Q
ASA for PET prevention:
a) dose
b) when to start
c) when
A
a) 81-162mg PO QHS
b) before 16wks
c) 36-37wks
19
Q
TOLAC with 2 prior c-sections:
a) rate of success
b) rate of uterine rupture
c) risks
A
a) similar to one prior c-section
b) 1.6%
c) increased risk of uterine rupture, blood transfusion, hysterectomy
20
Q
contraindications to planned vaginal breech birth? (8)
A
- footling breech
- cord presentation
- growth restriction (<2800g)
- LGA (>4000g)
- inadequate maternal pelvis
- fetal anomaly that may interfere with vaginal delivery
- hyper-extended fetal neck
- inability to perform urgent c-section
21
Q
is ECV contraindicated in patients with prior c-section?
A
no
22
Q
is oxytocin (induction or augmentation) contraindicated in breech deliveries?
A
no
23
Q
maneuvres/techniques to deliver entrapped after-coming head in vaginal breech birth?
A
- nitroglycerin
- Durssen incisions
- manual rotation of fetal head
- Prague maneuvre if OP
- Pipers forceps
- symphysiotomy
- Zavanelli maneuvre
24
Q
recommended time cut-offs for second stage for vaginal breech birth:
a) passive second stage
b) active second stage
A
a) max 90 mins
b) max 60 mins
25
a) what is an incomplete breech presentation?
b) can these patients deliver vaginally?
a) both hips flexed but one knee is extended and one knee is flexed
b) yes
26
risk of uterine rupture for TOLAC vs ERCS?
TOLAC: 0.47%
ERCS: 0.026%
No 382 TOLAC
27
factors that increase risk of uterine rupture?
- 2 or more previous c-sections
- IOL requiring cervical ripening
- oxytocin use
- inter-delivery interval < 18 months
- "thin" LUS (no specific cut-off)
- previous classical or inverted T incision
No 382 TOLAC
28
contraindications to TOLAC?
- previous classical c-section
- previous inverted T or low vertical uterine incision
- previous uterine rupture
- previous major uterine reconstruction: full thickness myomectomy, repair of mullerian anomaly, cornual resection
- pts who decline TOLAC
not official CIs but need to be informed of increased risk:
- inter-delivery interval < 18 months
2 or more prior c-sections
- single layer closure
- unknown uterine incision
No 382 TOLAC
29
risk of neonatal death from uterine rupture?
6%
No 382 TOLAC
30
top 2 predictors of successful TOLAC?
- previous vaginal delivery: 86%
- spontaneous labor: 80.6%
No 382 TOLAC
31
neonatal risks of TOLAC vs ERCS?
TOLAC:
- seizures
- permanent neuro deficits
- death
ERCS:
- RDS
- TTN
No 382 TOLAC
32
most common sign of uterine rupture?
abnormal FHR:
- complicated variables
- late decels
- bradycardia
No 382 TOLAC
33
ABx for PP D&C?
not indicated
34
changes in fetal movement related to:
a) smoking
b) steroids
c) food temperature
a) temporarily decreases FM
b) decreases FM x 3 days after course of ACS
c) cold fluid increases FM
35
fetal monitoring recommended for pregnancies > 41wks?
BPP or NST + fluid assessment 2x per week
36
risks of IOL?
- tachysystole: +/- FHR changes
- cord prolapse
- chorioamnionitis
- uterine rupture
- operative delivery
- PPH
- failure to establish labor
- accidental iatrogenic PTB from incorrect dates
increased risk of c-section ONLY if cervix not ripe
37
contraindications to IOL?
- abnormal fetal lie/presentation: transverse, footling breech
- cord presentation
- active genital HSV
- invasive cervical carcinoma
- placenta previa
- vasa previa
- placenta accreta
- previous classical or inverted T incision c-sections
- significant prior uterine Sx, e.g. full thickness myomectomy
- previous uterine rupture
- pelvic structural deformities
- patient did not consent
also: unable to monitor fetus continuously, unable to perform urgent c-section
38
how long after administering misoprostol can you administer oxytocin?
4 hours
39
when is IOL recommended for AMA?
a) maternal age
b) GA
a) consider for maternal age >= 40
b) IOL by 40wks
considered biologically 2 weeks behind pts under age 40 (i.e. 39wk AMA patient has similar placental function as 41wks in pts < age 40)
40
IOL vs expectant management for SRM at term?
- less chorioamnionitis: RR 0.62
- less endometritis: RR 0.59
- less neonatal sepsis: RR 0.46
- less NICU admission: RR 0.54
- higher chance of delivery within 24hrs of SRM: RR 1.93
no significant difference in c-section rate: RR 0.97
41
when can you safely start oxytocin after cervical ripening agents?
a) PGE2 gel insertion(Prostin)
b) PGE2 insert removal (Cervidil)
c) oral PGE1 administration
d) vaginal PGE1 insertion
a) 6 hours
b) 30 minutes
c) 2 hours
d) 4 hours
42
high priority indications for IOL? (7)
- suspected fetal compromise
- significant maternal disease, not responding to Tx
- significant but stable APH
- chorioamnionitis
- PET without severe features at >= 37wks
- PET with severe features, at any GA
- GBS positive SRM at term
43
rank importance of the different components of the Bishop score
1 - dilation
2 - effacement
3/4 - station/position
5 - consistency
44
factors that increase IOL success? (6)
- Bishop score >= 7
- BMI < 40
- maternal age < 35
- previous vaginal delivery
- no Hx DM/GDM
- EFW < 4000g
45
ways to avoid operative vaginal delivery? (8)
- accurate pregnancy dating
- avoid IOL, unless indicated
- continuous support in labor
- use IA in low risk pts
- appropriate time intervals for pushing
- delayed onset of pushing with epidural
- appropriate use of amniotomy + oxytocin
- optimize fetal position if OP or OT
46
NNT for membrane sweep at 38wks to prevent post-dates pregnancy?
NNT = 8
47
rate of perinatal mortality for vaginal breech birth vs elective c-section for breech?
a) vaginal breech birth: 0.8-1.7 per 1000
b) elective c-section: 0-0.8 per 1000
48
short vs long-term neuro outcomes for vaginal breech birth vs elective c-section?
- increased short term morbidity for planned VBB
- no diff in long-term neuro morbidity
- risk of CP: 1.5 per 1000 for both
49
how long do you allow a passive second stage for vaginal breech birth?
90 mins
50
how long do you allow an active (pushing) second stage for vaginal breech birth?
60 mins
51
how long do you allow in TOTAL the for second stage of labor:
a) nullip, no epidural
b) nullip, with epidural
c) multip, no epidural
d) multip, with epidural
a) 3 hours
b) 4 hours
c) 2 hours
d) 3 hours
No 415 Impacted fetal head
52
definitions of labor dystocia:
a) active first stage
b) active second stage
a) > 4 hours of cervical change at < 0.5 cm/hr, or no dilation over 2 hours
b) greater than 1 hour of pushing without descent
53
definition of obstructed labor?
no dilation or descent over 2 hours, despite evidence of strong uterine contractions (presence of caput and/or moulding; IUPC)
54
adequate contractions measured by IUPC?
each ctx 50-60 mmHg, OR > 200 mVu over 10 mins
55
frank vs complete breech?
frank breech: hips flexed + knees extended
complete breech: hips flexed + knees flexed (COMPLETELY flexed)
56
use of oxytocin for vaginal breech birth?
not contraindicated
- acceptable for augmentation
- limited data for IOL but does not appear to be associated with poorer outcomes vs spontaneous labor
57
when to consider c-section for labor dystocia for vaginal breech birth?
- no cervical dilation over 2hrs
- more than 7 hours to go from 5 to 10 cm
58
monitoring for vaginal breech in labor?
continuous EFM
59
definitions for assisted vaginal birth:
a) high
b) mid
c) low
d) outlet
a) fetal head not engaged (above station 0): this is NOT recommended
b) fetal station 0 to +2, OR fetal head no more than 1/5 palpable above pubic brim
c) leading bony part of fetal head is at station +2 or greater
d) fetal scalp visible without labial separation, OR fetal skull at pelvic floor
No 381 AVD
60
contraindications to assisted vaginal birth?
a) absolute (7)
b) relative (1)
a) absolute CIs:
- non-vertex presentation (EXCEPT forceps for face presentation or after-coming head in vaginal breech)
- unengaged fetal head: more than 1/5 of fetal head palpable abdominally
- incomplete cervical dilation
- uncertain fetal position
- suspected CPD
- fetal coagulopathy, thrombocytopenia, or brittle skeletal dysplasia
- inability to progress to timely c-section if unsuccessful
b) relative CIs
- vacuum at < 34wks
No 381 AVD
61
prerequisites for assisted vaginal birth
- patient consent
- documented physical exam: dilation, effacement, station, fetal position
- preparation of staff: including anesthesia + NICU
- location of delivery: considering bed, lighting, fetal monitoring, proximity to emergency c-section
- analgesia
- empty bladder
No 381 AVD
62
indications for assisted vaginal birth
1. abnormal FHR in second stage
2. labor dystocia in second stage
3. maternal conditions that preclude/limit valsalva:
- NYHA 3/4
- severe resp dz
- cerebral AVM
- proliferative retinopathy
- myasthenia gravis
- SCI at risk of autonomic dysreflexia
No 381 AVD
63
preferred episiotomy type?
mediolateral episiotomy: with incision at 60-70 degrees from vertical, starting 1cm lateral from the midline
No 381 AVD
64
neonatal risks associated with forceps?
- facial lacerations
- external ocular trauma
- intracranial hemorrhage
- subgaleal hemorrhage
- retinal hemorrhage
- facial nerve injury
- skull fracture
- death
No 381 AVD
65
neonatal risks of forceps vs vacuum
stats for forceps:
- scalp injury: RR 1.29
- facial injury: RR 7.17
- intracranial injury: RR 1.37
- cephalohematoma: RR 0.41
- retinal hemorrhage: RR 0.66
vacuum also associated with higher risk of shoulder dystocia + brachial plexus injury
No 381 AVD
66
neonatal risks associated with vacuum?
- intracranial hemorrhage
- scalp abrasions/lacerations
- cephalohematoma
- retinal hemorrhage
- brachial plexus injury
No 381 AVD
67
pathophysiology of subgaleal bleed?
tearing of large emissary veins which lie below aponeurosis; not limited to suture lines therefore can be associated with large volume of bleeding
No 381 AVD
68
pathophysiology of cephalohematoma?
bleeding between bony skull + periosteum; limited by suture lines but can be associated with hyperbili
risk with vacuum: 5%
No 381 AVD
69
Maternal risks of assisted vaginal birth? (9)
- increased blood loss
- increased pain
- lower genital laceration
- hematoma (vulvar, vaginal)
- OASIS
- urinary tract injuries
- urinary incontinence
- prolapse
- psych trauma
note that second stage c-section has higher risk of PTB in subsequent pregnancies
No 381 AVD
70
name interventions to promote spontaneous vaginal delivery (6)
- dedicated support person
- use IA (instead of CEFM) for low risk patients
- augment with oxytocin
- allow increased pushing time with epidural
- labor down with epidural
- manual rotation for malposition
No 381 AVD
71
List meds (5) + doses (including low vs high dose protocols; continuous + cyclic regimens) for conservative management of endometrial hyperplasia
1. medroxyprogesterone acetate (MPA)
- oral, low dose, continuous: Provera 2.5-20 mg / day - oral, high dose, continuous: Provera 100-200 mg / day
- oral, cyclic: Provera 10-20 mg / day x 10-12 days / cycle
- injectable: Depo-Provera 150 mg IM Q 90 days
2. megestrol acetate (MA)
- oral, low dose, continuous: Megace 40 mg / day
- oral, high dose, continuous: Megace 80-320 mg / day
3. norethindrone acetate (NETA)
- oral, continuous: Norlutate 5-15 mg / day
- oral, cyclic: Norlutate 15 mg / day x 10-12 days / cycle
4. progesterone: Prometrium 100-300 mg / day
5. LNG-IUS: Mirena 52 mg per unit = 20 mcg / day
72
List ways to assess FHS antenatally (7)
1. fetal movement counts
2. SFH
3. biometry
4. BPP
5. AFV assessment
6. Dopplers
7. NST
No 441 Antenatal FHS
73
When to initiate fetal movement counting?
26 weeks
No 441 Antenatal FHS
74
How should AFV be assessed on US for:
a) oligo
b) poly
a) using single deepest pocket (SDP): oligo if < 2 x 1cm pocket. Using AFI (< 5cm) for oligo is a/w more interventions WITHOUT improved neo outcomes
b) can use SDP (> 8 x 1 cm) and/or AFI (>= 25 cm). AFI can be used to classify as mild, mod or severe
No 441 Antenatal FHS
75
Recommendations for BPP 10/10 or 8/10 (normal fluid)?
Risk of asphyxia extremely rare (perinatal mortality 1/1000 within 1 week): intervention if other OB/maternal indications
No 441 Antenatal FHS
76
Recommendations for BPP 8/10 (abnormal fluid)?
Probable chronic fetal compromise (perinatal mortality 89/1000 within 1 week):
- assess for ruptured membranes
- rule out fetal renal anomaly
- consider delivery if at term
- if < 34wks increase surveillance
No 441 Antenatal FHS
77
Recommendations for BPP 6/10 (normal fluid)?
Equivocal test; possible asphyxia (variable perinatal mortality); repeat BPP within 24hrs
No 441 Antenatal FHS
78
Recommendations for BPP 6/10 (abnormal fluid)?
Probable asphyxia (perinatal mortality 89/1000 within 1 week):
- delivery recommended if at term
- if < 34wks increase surveillance
No 441 Antenatal FHS
79
Recommendations for BPP 4/10?
High probability of asphyxia (perinatal mortality 91/1000 within 1 week):
- delivery usually indicated
- if < 32wks: individualized management, extended monitoring may be appropriate
No 441 Antenatal FHS
80
Adverse pregnancy outcomes associated with adenomyosis? (7)
- PET (OR 4.32)
- FGR
- GHTN
- malpresentation
- PPH
- PTB
- c-section
No 437 adeno
81
Features that can be used to diagnose adenomyosis on 3D-US? (3)
- poorly defined, irregular, interrupted junctional zone
- junctional zone thickness >= 8mm
- >= 4mm difference between maximum + minimum thickness of junctional zone
No 437 adeno
82
MRI features of adenomyosis?
a) direct features
b) indirect features
a)
- myometrial cysts
- adenomyoma
c) external adenomyosis (aka involving serosa, but not junctional zone)
b)
- junctional zone thickness > 12mm
- junctional zone differential > 5mm
- ratio of junctional zone to myometrium > 40%
- enlarged uterus
No 437 adeno
83
Risks of uterine-sparing surgery for adenomyosis (short + long term)? (6)
- hemorrhage +/- transfusion
- emergency hysterectomy
- Asherman's syndrome
- uterine rupture
- placenta accreta
- possibly no improvement in fertility
No 437 adeno
84
Risks associated with IOL? (8)
- tachysystole +/- FHR changes
- cord prolapse
- chorioamnionitis
- uterine rupture
- operative delivery (AVD or c-section)
- PPH
- failed IOL
- adverse neo outcomes (i.e. if preterm IOL)
No 432a IOL
85
High priority indications for IOL?
- suspected fetal compromise
- significant maternal disease, not responsive to Tx
- significant but stable APH
- chorioamnionitis
- PET/HELLP
- PROM at/near term in GBS pos patients
No 432a IOL
86
Contraindications to IOL? (11)
- abnormal fetal presentation (incl transverse + footling breech)
- cord presentation
- previous uterine rupture
- significant previous uterine surgery (incl full thickness myomectomy, classical c-section or inverted T incision)
- placenta previa
- placenta accreta
- vasa previa
- active genital HSV
- invasive cervical cancer
- pelvic structural deformities
- patient does not consent
No 432a IOL
87
Ways to prevent IOL?
- accurate pregnancy dating
- membrane sweeping: NNT 8!
- nipple stim
- castor oil
No evidence for intercourse
No 432a IOL
88
EFW cutoffs to consider elective c-section? (2)
Patients w/ DM: EFW > 4500g
Patients without diabetes: EFW > 5000g
No 432a IOL
89
Can misoprostol be used for cervical ripening in patients with prior c-section?
Not at term: increased risk of uterine rupture
Can be used for TOP in T1/T2 (usually at decreased doses)
No 432b cervical ripening
90
When is it safe to start oxytocin after using cervical ripening?
a) after PGE2 gel (prostin gel)
b) after removal of PGE2 vaginal insert (cervidil)
c) after oral PGE1 (misoprostol)
d) after PV PGE1
a) 6hrs
b) 30mins
c) 2hrs
d) 4hrs
No 432c IOL
91
Options for IOL with intact membranes and favorable Bishops score?
- PGE1: multiple routes incl PO + PV
- PGE2 gel/inserts
- oxytocin + ARM
PO misoprostol or oxytocin/ARM are the preferred methods for Bishop score >= 7
No 432b cervical ripening
92
Risk factors for PPH from uterine atony?
- LGA
- multiple gestation
- polyhydramnios
- precipitous labor
- prolonged labor
- prolonged use of oxytocin
- high parity
- anemia
- use of general anesthetic
- prolonged ROM
- chorioamnionitis
- fibroids
- placenta previa
- full bladder
No 431 PPH
93
Risk factors for PPH from tissue?
- retained placenta
- placental abnormalities, e.g. succenturiate lobe
- placenta accreta
No 431 PPH
94
Risk factors for PPH from trauma?
- precipitous vaginal delivery
- AVD
- fetal malposition
- LGA
- extension of episiotomy
- fundal placenta
- previous uterine Sx
specific to c-section:
- need for classical or inverted-T at c-section
- deeply impacted fetal head
- prolonged second stage
No 431 PPH
95
Components of active management of the third stage of labor? (updated - PPH guideline)
traditionally included:
- PPx uterotonics at time of delivery of anterior shoulder
- early cord clamping
- controlled cord traction
now only refers to PPx uterotonics using:
- IM or IV oxytocin for low-risk patients
- IV oxytocin for high-risk patients
No 431 PPH
96
Discuss mechanism of action, dosing + contraindications for PPH meds:
a) oxytocin
b) ergometrine
c) carboprost
d) misoprostol
e) TXA
a) oxytocin
- MOA = uterotonic, acts on oxytocin receptors in uterus
- Tx dose is 20-40 IU/L infusion given rapidly over > 4 minutes, followed by infusion at 7-15IU/hr
- CIs: /
b) ergometrine
- MOA = ergot alkaloid, stimulates contractions of uterus + vascular smooth muscle
- dose: 250 mcg IM or IV, can repeat q 2hrs x 5 doses
- CIs: HTN, use of protease inhibitors for HIV Tx, macrolide ABx
c) carboprost
- MOA = prostaglandin F2-alpha, causes contractions in myometrial + intestinal smooth muscle cells
- dose: 250mcg IM or IMM, can repeat q 15 min x 5 doses (CANNOT given IV)
- CIs: severe asthma
d) misoprostol
- MOA = prostaglandin E1 analog, uterotonic
- multiple routes of administration: PR is inferior
- highest bioavailabilty + rapid onset for SL 200-400mcg
- CIs: /
e) TXA
- MOA = anti-fibrinolytic (NOT a uterotonic)
- dose: 1G IV, can repeat q 30 min x 2 doses
- CIs: /
No 431 PPH
97
Considerations for use of Bakri balloon for PPH?
- can fill with 300-500cc sterile solution
- Foley in bladder
- leave Bakri for 8-48hrs before gradually deflating
- PPx ABx recommended
No 431 PPH
98
Management of uterine inversion?
- if placenta still attached, do NOT remove prior to replacing uterus
- attempt immediate replacement
- transfer to OR
- Nitroglyerin 50-100mcg IV for uterine relaxation
- once replaced: bimanual massage + give uterotonics
- consider Bakri to keep in place
if unsuccessful: laparotomy is required
- Huntington procedure
- Haultain incision
- compression sutures, once replaced
No 431 PPH
99
How to perform artery ligation for PPH:
a) uterine arteries
b) internal iliac arteries
Use absorbable suture on large needle
a) secure uterine artery at level of isthmus = 2-3cm below level of uterine incision, incorporating 2cm of myometrium into bites to prevent complete vessel occlusion
b) retroperitoneal dissection is required: identify bifurcation of common iliac into internal + external branches, ligate internal iliac branch > 2cm distal to the bifurcation
No 431 PPH
100
most common reported symptom of endometriosis?
dysmenorrhea
- 50-80% of pts with endo report dysmenorrhea
- up to 70% of pts with dysmenorrhea will be Dx with endo
No 449 Diagnosis of endo
101
incidence of infertility in patients with endo?
10-30%
No 449 Diagnosis of endo
102
risk of malignancy in an endometrial polyp?
0.5-5%
can be as high as 13% in patients with risk factors
No 447 Diagnosis + mgmt of polyps
103
risk factors for malignancy within an endometrial polyp?
- postmenopausal
- age > 60
- postmenopausal bleeding
- Tamoxifen
No 447 Diagnosis + mgmt of polyps
104
how can you remove polyps at time of hysteroscopy? (4)
- scissors/graspers
- cold loop
- tissue removal systems, e.g. Myosure
- resectoscope
No 447 Diagnosis + mgmt of polyps
105
complications from hysteroscopic polypectomy?
a) intra-op
b) post-op
a)
- uterine perforation
- intra-abdominal visceral injury
- fluid overload
- hemorrhage
- anesthetic complications
b)
- infection
-hemorrhage
- intrauterine adhesions
No 447 Diagnosis + mgmt of polyps
106
incidence of polpys in patients with infertility?
6-32%
No 447 Diagnosis + mgmt of polyps
107
cardiac side effects associated from oxytocin use?
vasoconstriction, leading to ST depression
No 431 PPH
108
doses of oxytocin in labor for:
a) active management of third stage of labor
b) therapeutic dose for PPH
a) 3 IU IV rapid injection OR 10 IU IM
b) 20-40 IU/L infusion given rapidly over > 4 mins, followed by 7-15 IU/hr maintenance once adequate tone
No 431 PPH
109
role for carbetocin in PPH?
can consider PPx carbetocin at time of c-section at a dose of 100 mcg IV
provides similar clinical effects + side effects as 5 IU IV oxytocin
longer half life, therefore may require LESS additional uterotonics
No 431 PPH
110
oxytocin-free interval before c-section?
recommended to have oxytocin wash-out of 1hr prior to c-section for labor dystocia, assuming mom/baby are stable
No 431 PPH
111
what is the lethal triad associated with PPH?
coagulopathy
acidosis
hypothermia
No 431 PPH
112
when to activate massive transfusion protocol?
4 units of blood given + ongoing blood loss
No 431 PPH
113
threshold to replace blood products in PPH with respect to ...
a) Hb
b) platelets
c) PTT/INR
d) fibrinogen
a) aim to keep Hb above 70-90 during active hemorrhage
b) transfuse platelets if < 75; aim to keep levels > 50
c) give FFP; aim to keep INR < 1.8
d) replace if < 2g/L; can use either cryoprecipitate or fibrinogen concentrate
as per MTP protocol: after 4 units of blood, ratios are 1:1:1 or 2:1:1 for pRBCs:plts:FFP
No 431 PPH
114
management options when maternal HR artefact is suspected during FHR monitoring? (4)
- optimize position of FHR transducer
- monitor maternal HR using pulse oximeter
- use POCUS to confirm FHR + appropriately position FHR transducer
- apply FSE
No 429 Maternal HR artefact
115
contraindications to use of FSE? (8 absolute; 2 relative)
- HIV
- hepatitis
- active genital herpes
- suspected fetal bleeding disorder
- intact membranes + amniotomy not possible
- face presentation
- presenting part uncertain
- placenta previa
use with caution if:
- intrauterine infection
- less than 32wks gestation
No 429 Maternal HR artefact
116
recommendations for delayed cord clamping:
a) term infants
b) preterm infants
a) 60 seconds
b) 60-120 seconds
No 424 Umbilical cord mgmt
117
benefits to delayed cord clamping:
a) term infants
b) preterm infants
a) DCC > 60 seconds associated with:
- improved Hb, iron, ferritin + transferrin sats
- lower rates of iron deficiency anemia
b) DCC 60-120 seconds associated with:
- decreased mortality (30%)
- decreased IVH (RR 0.83)
- decreased NEC (RR 0.59)
- decreased neo blood transfusion (RR 0.66)
- decreased need for inotropes (RR 0.37)
- decreased adverse neurodevelopmental outcomes at age 2
No 424 Umbilical cord mgmt
118
contraindications to delayed cord clamping?
absolute CIs:
- need for immediate maternal or neo resus
- hydrops
- certain fetal anomalies, e.g. diaphragmatic hernia
- bleeding placenta previa
- bleeding vasa previa
- abruption
- placental transection
relative CIs:
- risk factors for significant neo hyperbilirubinemia, e.g. severe IUGR, pre-GDM, polycythemia
- high maternal antibody titers
- first infant in monochorionic twins
No 424 Umbilical cord mgmt
119
should you do umbilical cord milking in preterm infants?
not in infants < 32 weeks gestation: associated with significant increase in severe IVH
No 424 Umbilical cord mgmt
120
risks associated with female genital cosmetic surgery?
- bleeding
- infection
- wound dehiscence
- injury (urethra, clitoris, vulva, rectum)
- post-op pain
- scarring
- altered sensation + sexual pleasure
- unexpected altered anatomy (e.g. asymmetry)
No 423 Female genital cosmetic surgery
121
age of majority in Canada with respect to consent for surgery/procedures?
rejected by Canadian courts: instead, "mature minors" are recognized as persons who can understand benefits/risks of treatments
EXCEPTION = Quebec, where the age of consent is 14 years old
No 423 Female genital cosmetic surgery
122
top 2 reasons that female adolescents request genital cosmetic surgery?
#1 - relief of functional symptoms, e.g. pain, friction
#2 - the patient's mother believes the daughter has anatomic abnormalities
No 423 Female genital cosmetic surgery
123
risk reduction for VTE prophylaxis in hospitalized patients?
60%
VTE is considered the most common preventable death in hospitalized patients
No 417 Prevention of VTE in Gyne surgery
124
role of compression stockings in VTE PPx?
can use intermittent pneumatic compression devices (IPCs) or graduated compression stockings (GCSs)
both decrease bloos stasis in lower leg veins
IPCs preferred over GCSs: IPCs reduce risk of DVT by 60% (vs no VTE PPx)
No 417 Prevention of VTE in Gyne surgery
125
risk reduction for unfractionated heparin for peri-op VTE for Gyne surgery?
reduces risk of non-fatal PE by 41%
reduces risk of fatal PE by 47%
no associated increase in bleeding or blood transfusion
No 417 Prevention of VTE in Gyne surgery
126
advantages vs disadvantages of unfractionated heparin vs LMWH for Gyne surgery VTE PPx?
UF - advantages:
- well studied efficacy
- low cost
- can reverse with protamine sulfate
- safe for patients with renal dysfunction
disadvantages:
- risk of post-op bleeding
- higher risk of HIT
- more frequent dosing required
- less predictable pharmacokinetics
LMWH - advantages:
- greater bioavailability
- once daily dosing
- predictable pharmacokinetics
- lower risk of osteoporosis
- lower risk of HIT
disadvantages:
- more expensive
- less studied in Gyne surgery
- must be administered 12hrs pre-op
No 417 Prevention of VTE in Gyne surgery
127
peri-op management of ASA?
discontinue 5-7 days pre-op + restart once hemostasis is guaranteed
consider continuing ASA peri-op, under consultation w/ cardiology, for patients with:
- significant CVD
- cardiac stents
- recent CABG
No 417 Prevention of VTE in Gyne surgery
128
pathophysiology of heparin induced thrombocytopenia?
production of auto-antibodies against endogenous platelet factor 4 (PF4), which activates platelets + leads to catastrophic coagulopathy and hemorrhage
mortality as high as 20-30%
No 417 Prevention of VTE in Gyne surgery
129
recommendations for peri-op management of:
a) OCPs
b) hormone therapy
in patients undergoing Gyne surgery?
a) OCPs: no indication to stop, in patients at low risk of VTE
can consider stopping in patients at high risk x 4 weeks pre-op until 6-12 weeks post-op (will require alternative contraception during that time)
b) MHT: no indication to stop in patients at low risk of VTE
can consider switching from PO to TD formulations, as this is lower risk of VTE
No 417 Prevention of VTE in Gyne surgery
130
role of IVC filters as VTE PPx in patients undergoing Gyne surgery?
no evidence to support this as PPx
can be considered to prevent PEs in patients with known DVTs
No 417 Prevention of VTE in Gyne surgery
131
approach to nulliparous and/or young patients requesting permanent contraception?
this can be provided, as long as patients are adequately counselled + capable of voluntary consent
No 419 Coercion free contraception
132
how often during the second stage should you assess for progress?
assess the following every hour:
- adequate ctx (consider augmentation)
- fetal descent
- fetal position
- signs of obstructed labor (caput, moulding)
No 415 Impacted fetal head
133
can you do a tubal ligation at time of c-section?
yes - if patient has been adequately counselled during antenatal care + this discussion is clearly documented
NOT recommended to do if patient requests tubal at time of emergency c-section
No 419 Coercion free contraception
134
maternal complications of impacted fetal head?
intra + post-op complications:
- hemorrhage
- wound infection
- endometritis
- extensions
- bladder injury
complications in subsequent pregnancies:
- PTL/PTB
- PPROM
- cervical insufficiency
No 415 Impacted fetal head
135
fetal/neonatal complications of impacted fetal head?
- skull fractures
- long bone fractures
- lacerations
- low APGARs
- NICU admissions
No 415 Impacted fetal head
136
what is the Whitmore position?
aka modified Lithotomy
consider for c-sections with suspected impacted fetal head
No 415 Impacted fetal head
137
what is a Bandl's ring?
pathologic constriction between the thickened upper contractile uterine segment + thinned out lower uterine segment; may be encountered during c-section for obstructed labor
may need to incise this to facilitate delivery
No 415 Impacted fetal head
137
dose of nitroglycerin to facilitate delivery of impacted fetal head?
50-200 mcg IV
relaxation should occur within 30-45 sec; effects last 2 mins
No 415 Impacted fetal head
138
what fetal position facilitates the pull technique for delivering an impacted fetal head?
occiput posterior
No 415 Impacted fetal head
139
compare the pull vs the push technique for impacted fetal head
pull technique is associated with:
- lower risk of fetal injury
- less damage to maternal tissue
- less overall blood loss
No 415 Impacted fetal head
140
what is the Patwardhan technique + what is it used for?
technique to deliver an impacted fetal head at time of c-section
deliver the anterior shoulder, then posterior shoulder, then buttocks, then legs, then the fetal head
associated with lower rates of extensions vs the push technique
No 415 Impacted fetal head
141
what % of maternal deaths are attributed to ectopic pregnancies?
75% of maternal deaths in first trimester
9-13% of all pregnancy-related deaths
No 414 Management of PUL + ectopics
142
incidence of ectopic pregnancies?
1-2%
98% are in the fallopian tube
No 414 Management of PUL + ectopics
143
rates of non-tubal sites of ectopic pregnancies?
hysterotomy or c-section scar ectopic: 1 in 2000
abdominal ectopic: 1 in 5000
ovarian ectopic: 1 in 7000
cervix: rare
rudimentary horn: rare
No 414 Management of PUL + ectopics
144
possible outcomes of a pregnancy of unknown location? (4)
failed PUL: 44-69%
intrauterine pregnancy (viable or non-viable): 34-40%
ectopic pregnancy: 8-14%
persistent pregnancy of unknown location: 2%
No 414 Management of PUL + ectopics
145
progesterone cut-off used in M6 model for risk of ectopic?
2 nmol/L
progesterone =< 2 nmol/L is a probable failed PUL
progesterone > 2 nmol/L requires further surveillance: could represent failed PUL vs ectopic vs intrauterine pregnancy
No 414 Management of PUL + ectopics
146
factors to consider for expectant management vs active treatment of a tubal ectopic? (table)
No 414 Management of PUL + ectopics
147
single dose protocol for methotrexate for management of tubal ectopics?
dose = 50mg/m2 IM (based on body surface area)
check betas on day 1, 4 and 7
if >= 15% drop in beta from day 4 to 7: follow betas weekly until negative
if < 15% drop: give a second dose of MTX 50mg/m2 IM
No 414 Management of PUL + ectopics
148
teratogenesis associated with methotrexate?
mainly CNS abnormalities:
- craniosynostosis = pathognomonic finding
- open NTDs
- hydrocephalus
- anencephaly
also associated with:
- skeletal abnormalities
- IUGR
No 414 Management of PUL + ectopics
149
selection criteria for medical management of tubal ectopics? (table)
No 414 Management of PUL + ectopics
150
absolute contraindications to methotrexate?
- clinically significant liver dz
- clinically significant renal dz
- blood dyscrasias
- bone marrow suppression
- peptic ulcer disease
- pulmonary fibrosis
- immunosuppression
- chronic infections
- heterotopic pregnancy
- breastfeeding
No 414 Management of PUL + ectopics
151
salpingotomy vs salpingectomy for management of ectopic pregnancy?
NO evidence to recommend salpingotomy over salpingectomy when the contralateral tube is normal with respect to fertility
salpingotomy also associated with higher risk of recurrent ectopic + requires post-Tx follow-up
No 414 Management of PUL + ectopics
152
types + management of c-section scar ectopics?
type 1: pregnancy progresses to cervico-isthmic space of uterine cavity
- can result in viable pregnancy
- can be Tx expectantly
- surgical management: hysteroscopy
type 2: deep invasion of c-section scar towards bladder/abdominal cavity
- may be associated with uterine rupture
- may evolve into placenta accreta, if pregnancy progresses
- can consider MTX (systemic or local) but 50% will still require surgery
- surgical management: laparoscopy or laparotomy, with concurrent repair of c-section scar defect
No 414 Management of PUL + ectopics
153
management + subsequent pregnancy risks of interstitial/cornual ectopic pregnancies?
laparoscopic cornuotomy or wedge resection
30% risk of uterine dehiscence in subsequent pregnancy
also risk of recurrent interstitial/cornual pregnancy
No 414 Management of PUL + ectopics
154
management of heterotopic pregnancies?
can offer intralesional MTX in appropriately selected patients
systemic MTX is contraindicated in the presence of a viable + desired IUP
surgery is recommend to excise the ectopic pregnancy: can do concurrent D&C if the IUP is not desired
No 414 Management of PUL + ectopics
155
rate of intra-op injuries from laparoscopic Gyne surgery?
1 in 1000
No 412 Laparoscopic entry
156
techniques for laparoscopic entry for Gyne surgery? (3)
- closed entry: Veress needle
- open entry: Hasson
- direct trocar insertion
no single method is considered safer/superior
No 412 Laparoscopic entry
157
when should alternative Veress entry points to subumbilical entry be considered?
- after 3 failed attempts at umbilical entry
- when umbilical entry is complicated
complicated umbilical entry:
- extremes of BMI
- known or suspected periumbilical adhesions
- Hx of umbilical hernia
No 412 Laparoscopic entry
158
% of patients with peri-umbilical adhesions?
no prior abdominal surgery: < 1%
prior laparoscopic surgery: 0-15%
prior horizontal laparotomy: 20-28%
prior vertical laparotomy: 50-60%
No 412 Laparoscopic entry
159
how do you landmark Palmer's point?
3 cm below left subcostal border, in the midclavicular line
insert Veress at 90 degrees
No 412 Laparoscopic entry
160
contraindications to laparoscopic entry with Palmer's point? (4)
- significant hepatosplenomegaly
- portal hypertension
- previous splenic or gastric surgery
- gasto-pancreatic mass
No 412 Laparoscopic entry
161
best indicator of correct abdominal entry with Veress needle?
intraperitoneal pressures < 10 mmHg
No 412 Laparoscopic entry
162
discuss Hasson vs Veress needle with respect to:
a) vascular injuries
b) bowel injuries
a) Hasson has lower incidence of vascular injuries
b) Hasson has potentially higher incidence of bowel injuries: although likely selection bias
No 412 Laparoscopic entry
163
how/where can you enter the abdomen laparoscopically during pregnancy?
a) < 14 wks
b) 14-24 wks
c) > 24 wks
a) can use Veress or Hasson through the umbilicus
b) can use Hasson at umbilicus, or Veress at Palmer's point
c) Hasson
No 412 Laparoscopic entry
164
which ovarian masses typically have benign features on US? (5)
- simple or unilocular cysts
- hemorrhagic cysts
- endometriomas
- dermoids
- fibromas
No 404 Benign adnexal masses
165
management of asymptomatic simple ovarian cysts?
repeat US in 8-12 weeks, then annually x 5 years
simple ovarian cysts < 10cm should NOT be removed in asymptomatic premenopausal patients:
- most resolve without treatment
- risk of malignancy < 1%
No 404 Benign adnexal masses
166
risk of malignant transformation of endometriomas or dermoids?
< 1%
increased risk (1-10%) if > 10cm in diameter or contains a solid vascular component
No 404 Benign adnexal masses
167
most common ovarian masses associated with torsion? (3)
- benign hemorrhagic cysts
- dermoids
- serous cystadenomas
No 404 Benign adnexal masses
168
above what size (diameter) is an ovarian lesion more likely to tort?
diameter > 5cm accounts for 80% of cases of torsion
No 404 Benign adnexal masses
169
risk of spillage during laparoscopic ovarian cystectomy?
12-25%
No 404 Benign adnexal masses
170
how to prevent recurrent ovarian cysts?
suppress ovulation: CHCs are first line
note that POPs + LNG-IUS are associated with INCREASED formation of functional ovarian cysts
No 404 Benign adnexal masses
171
IOTA components for assessment of ovarian masses? (table)
considered benign if 1 or more B features + no M features
considered malignant if 1 or more M features + no B features
intermediate if both M and M features present, or if no rules apply
No 403 Investigation/mgmt of adnexal masses
172
Gyne conditions that may lead to a false positive Ca-125?
Gyne conditions:
- menses
- pregnancy
- endometriosis
- benign adnexal masses
- adenomyosis
- fibroids
- PID
No 403 Investigation/mgmt of adnexal masses
173
tumor markers for ovarian germ cell + sex cord stromal tumors? (table)
No 403 Investigation/mgmt of adnexal masses
174
types of female genital cutting?
type 1: partial/total removal of clitoris and/or prepuce
type 2: partial/total removal of clitoris + labia minora, +/- excision of labia majora
type 3 (aka infibulation): narrowing of vaginal orifice with creation of a covering seal (apposition of labia minora), +/- excision of the clitoris
type 4: unclassified, incl female genital cosmetic procedures, piercings, etc
No 395 Female genital cutting
175
risks associated with female genital cutting?
- pain
- bleeding
- infection
- unable to void/pass stool
- chronic pain
- epithelial inclusion cysts
- keloids
- blood borne viral infections
- sexual dysfunction
- PTSD
- lacerations with intercourse or labor
- obstructed labor
No 395 Female genital cutting
176
legal considerations for female genital cutting in Canada?
- illegal to perform/assist in FGC (infibulation)
- illegal to perform RE-infibulation
- report to child protection if a child is at risk of receiving FGC
DE-infibulation is acceptable + may be required/recommended to facilitate vaginal delivery or intercourse
No 395 Female genital cutting
177
is c-section required for type 3 female genital cutting?
no, although rates of c-section in labor are higher due to obstructed labor
could potentially lower c-section rates with antenatal DE-infibulation
No 395 Female genital cutting
178
how is complicated vulvovaginal candidiasis defined? (4)
- recurrent VVC: 4 or more episodes per year
- severe symptoms
- non-albicans species
- immune compromised patient
No 320 Vulvovaginitis
179
diagnosis of vulvovaginal candidiasis?
requires pelvic exam, with swabs
findings of thick white clumped discharge, PLUS erythema + edema of surrounding tissues, supports the Dx
may see budding yeast + pseudohyphae on wet mount
gram stain shows polymorphonuclear cells
No 320 Vulvovaginitis
180
treatment of uncomplicated vulovaginal candidiasis?
ONLY necessary in symptomatic patients
can use PO or PV antifungal azoles for uncomplicated VVC, e.g.
- clotrimazole 1% cream PV x 7 days
- fluconazole 150mg PO x 1 dose
in pregnancy:
- ONLY PV azoles can be used: PO fluconazole is associated with tetralogy of Fallot
- treatment may be required for up to 10-14 days
No 320 Vulvovaginitis
181
treatment of recurrent vulvovaginal candidiasis?
requires induction followed by maintenance Tx
options for induction:
- imidazole cream: e.g. clotrimazole 1% cream PV x 10-14 days
- fluconazole 150mg PO Q 3 days x 3 doses
- clotrimazole 500mg insert PV Qmonth x 6 months
- boric acid 300-600mg PV Qday x 14 days
options for maintenance:
- fluconazole 150mg PO Qweek
- ketoconazole 100mg PO Qday
- boric acid 300mg insert PV Qday x 5 days at beginning of menses
Tx may be required for up to 6 months for recurrent VVC
No 320 Vulvovaginitis
182
types of non-albicans species in vulvovaginal candidiasis?
- C glabrata
- C tropicalis
- C krusei
Dr Vair study session - misc Gyne content
183
treatment options for non-albicans vulvovaginal candidiasis?
- boric acid 300-600mg insert OV QHS x 14 days
- flucytosine 5G cream PV Qday x 14 days
- amphotericin B 50mg suppository PV Qday x 14 days
- nystatin 100 000 units suppository PV Qday x 3-6 months
No 320 Vulvovaginitis
184
what is the most common non-viral STI?
trichomonas vaginalis
prevalence of 3.1% in reproductive-aged women
No 320 Vulvovaginitis
185
diagnosis of trichomonas?
vaginal swabs for antigen testing, including NAAT or immunoassay
No 320 Vulvovaginitis
186
treatment of trichomonas?
metronidazole PO: either 2G PO Qday or 500mg PO BID x 7 days
treatment in pregnancy is recommended to prevent PTB
No 320 Vulvovaginitis
187
common species associated with bacterial vaginosis
DECREASED lactobacillus
INCREASED pathogenic bacteria:
- Garderella
- Mobiluncus
- Bacteroides
- Prevotella
- Mycoplasma
No 320 Vulvovaginitis
188
obstetrical complications associated with bacterial vaginosis?
- miscarriage
- subclinical PID
- PTB
- PPROM
- chorioamnionitis
- postpartum endometritis
- post-op wound infections
No 320 Vulvovaginitis
189
diagnosis of bacterial vaginosis?
can use either clinical or lab criteria
clinical = Amsel's criteria, requires at least 3 of the following 4:
- adherent + homogeneous vaginal discharge
- vaginal pH > 4.5
- clue cells on wet mount
- positive whiff test: amine odor after addition of KOH
lab = grain stain using objective scoring system
No 320 Vulvovaginitis
190
treatment of bacterial vaginosis?
metronidazole 500mg PO BID x 7 days
alternatives:
- metronidazole gel PV
- clindamycin PO or PV gel
No 320 Vulvovaginitis
191
treatment of bacterial vaginosis in pregnancy?
metronidazole 500mg PO BID x 7 days, or
clindamycin 300mg PO BID x 7 days
for patients at HIGH risk of PTB: PV metronidazole is recommended over PO
for patients at LOW risk of PTB: can use either PO or PV metronidazole
No 320 Vulvovaginitis
192
when are patients at highest risk of PID related to IUD insertion?
in the first 20 days after insertion
No 305 Minimizing infection with IUD insertion
193
should patients be screened for infection prior to IUD insertion?
STIs: screen by history + physical exam, and patients at increased risk SHOULD be tested prior to/at time of insertion (do not need to wait for results)
no evidence to support routine screening for BV at time of IUD insertion in asymptomatic patients
No 305 Minimizing infection with IUD insertion
194
how to manage an IUD in a patient with PID?
start treatment for PID
for mild to moderate PID, do NOT need to remove IUD unless patient requests removal
IF there is no clinical improvement after 48-72hrs of antibiotics, consider IUD removal
if the patient WANTS the IUD removed: should delay removal until after ABx to decrease risk of bacterial spread
No 305 Minimizing infection with IUD insertion
195
incidence of adnexal torsion for malignant adnexal lesions?
3% in adult cases
0-6% in peds cases
No 341 Torsion
195
ultrasound findings suggestive of ovarian torsion? (3)
- decreased/absent blood flow on Doppler
- increased total ovarian volume
- abnormal adnexal volume ratios (> 20 for volume of affected:unaffected ovary)
No 341 Torsion
195
when to consider oophoropexy at time of surgery for ovarian torsion? (3)
- congenitally long ovarian ligament
- repeat torsion
- when no obvious cause of torsion is found
196
should cystectomy be performed at time of ovarian detorsion?
no; even if "blue-black" ovary
should delay cystectomy for 6-8 weeks to avoid damage to normal ovarian tissue
No 341 Torsion
197
as per Canadian contraception survey (2006), what % of sexually active reproductive-age women who are NOT trying to conceive:
a) are using NO contraception?
b) are using contraception inconsistently?
a) 14.9% are using NO contraception
b) 20% are using contraception inconsistently
Canadian Contraception Consensus, Ch 1
198
define efficacy vs effectiveness with respect to contraception
efficacy: how many pregnancies are prevented during PERFECT use of a contraception method
effectiveness: how many pregnancies are prevented with TYPICAL use of a contraception method
Canadian Contraception Consensus, Ch 1
199
which contraceptives are the MOST effective at preventing pregnancy (top 3)?
#1 progesterone implant: 0.05%
#2 tubal ligation: 0.15%
#3 LNG-IUD: 0.2%
% of women experience pregnancy within first year of typical use
Canadian Contraception Consensus, Ch 1
200
what is the Yuzpe method for emergency contraception?
uses COCs to deliver 2 doses of ethinyl estradiol (100mcg per dose) and levonorgestrel (500mcg per dose), 12hrs apart
should only be used if other methods of emergency contraception are not available
200
when is the fertile window?
6 day window spanning from 5 days before ovulation to 1 day after ovulation
Canadian Contraception Consensus, Ch 3
200
compare the following options as emergency contraceptives:
a) ulipristil acetate
b) LNG-EC
c) copper IUD
d) LNG-IUD
a) UPA 30mg PO x 1 dose
- approved for up to 5 days after UPI
- Rx required
b) LNG-EC 1.5mg (750mcg x 2 tabs)
- approved for up to 3 days after UPI, but efficacy for up to 5 days
- available OTC as several options (e.g. Plan B)
c) copper IUD
- highly effective for EC up to 7 days after UPI
- added benefit of providing long-term contraception
d) LNG-IUD
- not currently approved for EC
- however, 2021 NEJM study shows LNG-IUD is not inferior to copper IUD for up to 5 days after UPI
Canadian Contraception Consensus, Ch 3
201
most effective method for emergency contraception?
copper IUD
most effective EC + also provides long-term contraception
Canadian Contraception Consensus, Ch 3
202
contraindications to using emergency contraception?
- pregnancy
- hypersensitivity to drug
- pelvic infection (for IUD)
patients with contraindications to regular use of CHCs can still safely use any hormonal method of EC
Canadian Contraception Consensus, Ch 3
203
when to start using contraception after taking hormonal emergency contraception?
LNG-EC: can start same day as taking LNG-EC ("quick start" method) but should use back-up contraception x 7 days
UPA-EC: delay CHC until 5 days after using UPA-EC due to concerns about CHCs interfering with UPA-EC
should use back-up contraception for 5 days after UPA-EC AND x 14 days after starting CHC
Canadian Contraception Consensus, Ch 3
204
components of lactational amenorrhea? (3)
- < 6 months postpartum
- (nearly) exclusively breastfeeding
- has remained amenorrheic
LAM is only an effective contraception option if ALL THREE criteria are met
Canadian Contraception Consensus, Ch 4
205
non-contraceptive benefit to salpingectomy (vs tubal ligation) as permanent contraception?
decreased risk of ovarian cancer: up to 40%
Canadian Contraception Consensus, Ch 6
205
risk of patient regret following permanent contraception?
20.3% of patients who had tubal before age 30
5.9% of patients who were above age 30
Canadian Contraception Consensus, Ch 6
205
how long should patients use back-up contraception after undergoing a permanent contraceptive procedure?
tubal ligation: 1 week
hysteroscopic occluson: 3 months, until bilateral tubal occlusion is confirmed on imaging
male vasectomy: until post-vasectomy semen analysis shows azospermia or < 100 000 non-motile sperm
Canadian Contraception Consensus, Ch 6
206
main cause of contraceptive failure for male vasectomy?
failure to use back-up contraception until post-procedure semen analysis confirms successful procedure
Canadian Contraception Consensus, Ch 6
207
contraindications to use of IUDs?
category 4:
- pregnancy
- current PID/purulent cervicitis
- puerperal sepsis
- immediate use post-septic abortion
- known distorted uterine cavity
- AUB not adequately investigated
- cervical or endometrial cancer, awaiting Tx
- malignant GTD
- pelvic TB
- LNG-IUD: current PR pos breast cancer
category 3:
- early postpartum (< 4wks)
- complicated solid organ transplant
- LNG-IUD: severely decompensated cirrhosis, malignant hepatoma or HCC
- LNG-IUD: Hx of PR pos breast cancer
Canadian Contraception Consensus, Ch 7
208
risk of uterine perforation at time of IUD insertion?
0.3-2.6 per 1000 insertions
Canadian Contraception Consensus, Ch 7
209
risk of ectopic pregnancy with IUD in situ?
lower risk with LNG-IUD than copper IUD
LNG-IUD: 0.02-0.2 per 100 women years
copper IUD: 0.08-0.8 per 100 women years
Canadian Contraception Consensus, Ch 7
210
approach to positive pregnancy test with IUD in situ?
- exclude ectopic pregnancy
- if IUP confirmed: should remove IUD, even if the patient plans to terminate the pregnancy
36.8% risk of adverse preg outcomes for removal vs 63.3% if left in situ (miscarriage, septic abortion, PTL/PTB, PPROM)
Canadian Contraception Consensus, Ch 7
211
should misoprostol be used prior to IUD insertion?
no: higher pain post-insertion + associated with its own side effects
Canadian Contraception Consensus, Ch 7
212
can you insert IUDs immediately postpartum?
yes, but associated with higher risk of uterine perforation + IUD expulsion after term pregnancy
can consider insertion immediately following T1 or T2 terminations to decrease risk of repeat abortion procedures
Canadian Contraception Consensus, Ch 7
213
how to manage actinomycosis on pap in IUD users?
seen in up to 20% of long-term copper IUD users
if asymptomatic:
- do NOT need to perform cultures
- leave IUD in place
- expectant management but discuss signs/sxs of infection
if symptoms of PID:
- remove IUD + send for culture (as per UTD)
- treat with Pen G, tetracycline or doxycycline
if severe symptoms:
- admit to hospital
- Tx for PID
- rule out associated abscesses
Canadian Contraception Consensus, Ch 7
214
mechanism of action for IUDs?
both prevent fertilization
LNG-IUD: thickens cervical mucus to prevent sperm entry
copper IUD: creates inflammatory "hostile" intrauterine environment that is toxic to sperm
Canadian Contraception Consensus, Ch 7
215
mechanism of action for contraceptive implants?
inhibition of ovulation
associated changes:
- thickens cervical mucus
- induces endometrial atrophy
Canadian Contraception Consensus, Ch 8
216
contraindications to progesterone implant (Nexplanon) for contraception?
category 4: current breast cancer
category 3:
- Hx of breast cancer
- severe cirrhosis
- HCC
- malignant liver tumor
- AUB not yet investigated
Canadian Contraception Consensus, Ch 8
217
effects of progestin-only contraceptives on bone mineral density?
depot provera: associated with decreased BMD due to estrogen deficiency
- this is reversible, once DMPA is discontinued
- no evidence that it causes osteoporosis or increases feacture risk
implant, POPs: BMD not affected
- ovulation is inhibited BUT endogenous estradiol production continues
- serum levels remain above threshold to maintain normal bone mass
Canadian Contraception Consensus, Ch 8
218
how long can return to fertility be delayed after stopping use of depot provera?
up to 1 year
Canadian Contraception Consensus, Ch 8
219
mechanism of action for progestin-only pills as contraceptives?
thickens cervical mucus
also suppresses ovulation in up to 50%
Canadian Contraception Consensus, Ch 8
220
contraindications to progestin-only pills as contraceptives?
category 4: current breast cancer
category 3:
- Hx of breast cancer
- severe cirrhosis
- HCC
- malignant liver tumor
- certain AEDs: phenytoin, carbamazepine, barbituates
- malabsorptive bariatric surgery
- rifampicin
Canadian Contraception Consensus, Ch 8
221
contraindications to combination OCPs?
category 4:
- smoking (>15 cigs per day) AND age > 35
- migraine with aura
- HTN (> 160/110)
- acute VTE
- Hx VTE + high risk of recurrence (incl Hx of VTE associated w/ OCP or pregnancy)
- SLE
- Hx of stroke
- known thrombophilia, incl APLS
- ischemic heart disease
- complicated valvular heart disease
- peripartum cardiomyopathy w/ mod/severe impaired function
- peripartum cardiomyopathy with normal function at < 6 months
- vascular disease
- current breast cancer
- severe cirrhosis
- hepatocellular adenoma
- malignant hepatoma
- < 4 weeks postpartum and breastfeeding
- < 3 weeks postpartum and NOT breastfeeding
- complicated solid organ transplant
- major surgery w/ prolonged immobilization
category 3:
- < 6 weeks postpartum w/ RFs for VTE
- Hx VTE but no other RFs for recurrence
- smoking < 15 cigs/day and age > 35
- MS + prolonged immobility
- HTN
- peripartum cardiomyopathy with normal cardiac function > 6 months
- Hx breast cancer
- symptomatic gallbladder disease
- acute/flare of viral hepatitis
- DM w/ microvascular disease
- Hx of COC-related cholestasis
- Hx malabsorptive bariatric surgery
- certain AEDs
Canadian Contraception Consensus, Ch 9
222
what is the only exam/investigation required before starting a patient on a combination OCP?
blood pressure measurement
Canadian Contraception Consensus, Ch 9
223
management of OCP use if active pills are skipped?
any # of missed pills, during week 1:
- take 1 active pill ASAP
- continue taking 1 pill daily until the end of the pack
- use back up contraception x 7 days
- consider EC
1-2 missed pills, during week 2 or 3:
- take 1 active pill ASAP
- continue taking 1 pill daily until the end of the pack
- then DISCARD placebo pills + start new pack
3 or more missed pills, during week 2 or 3:
- take 1 active pill ASAP
- continue taking 1 pill daily until the end of the pack
- then DISCARD placebo pills + start new pack
- use back-up contraception x 7 days
- consider EC
Canadian Contraception Consensus, Ch 9
224
list drugs that may interact with combination OCPs:
a) meds that might cause COC failure
b) meds whose effect might be altered by COCs
a)
- AEDs (barbituates, carbamazepine, phenytoin, topiramate)
- bile acid sequestrants
- protease inhibitors
- modafinil (used for narcolepsy)
- rifampin
- ulipristil acetate
- St John's wort
b) anticoagulants
- benzos
- beta blockers
- steroids
- lamotrigine
- mifepristone
-theophylline
- TXA
- TCAs
- ulipristil acetate
Canadian Contraception Consensus, Ch 9
225
