Structured Cases- OB

Question 1

fourth degree laceration repair - steps

Answer 1

1. rectal mucosa and submucosa running suture (3-0 vicryl)
   2) anal spinster 2-0 vircyl end to end
   3) second degree in usual fashion (3-0Vicryl)
   4) Skin closure
   5) Cefoxitin 2 grams decrease wound infeciton/breakdown

Question 2

fourth degree laceration EARLY breakdown- steps

Answer 2

1. OR for debridement of necrotic tissues and irrigated
2. obtain cultures
3. wait 7-10 days or until wound surface is covered by granulation tissue and NO EXUDATES
   *could repair earlier than 1 week
4. IV ambitious if cellulitis
5. Prior to full repair, enema, NPO, and consider bowel prep (controversial)
6. Perform re-debridement and 4 layer repair

Question 3

third/fourth degree DELAYED breakdown- steps

Answer 3

1. removal suture material
2. inspect anal sphincter
3. inspect for cellulitis/nec fasc
4. Then repair

Question 4

Recurrent OASIS risk… vs. CD

Answer 4

recurrent 3 %
Weight low risk fo recurrence with surgical risks CD
-second OASIS increase risks of sphincter damage/incontinence

Question 5

12 weeks post partum SVD with epis repair, now with dyspareunia.
DDX?
Treatment?

Answer 5

At 12 weeks PP, healing is complete and sutures are dissolved..

Ddx for dyspareunia: vestibulitis, vulvodynia, vaginismus, local infections, estrogen deficiency, PPD, painful scar tissue

Treatment for scar: local injection therapy or excision/revision

Question 6

26 yo at 38 weeks with EFW 4490, hx prior CD, hx macrosomia. Pregnancy healthy. How do you counsel her regarding mode of delivery?

Answer 6

1. In the absence of diabetes, CD would be indicated at EFW 5000.
2. TOLAC is reasonable, however lower success rate due to macrosomia (suspected) compared to normal size fetus
3. IF EFW >4500 and prolonged second stage or high arrest, indication for CD

Question 7

Maternal risk factors that increase risk of macrosomia?

Answer 7

1. DM: pregestational and GDM
2. pre-pregnancy obesity
3. excessive weight gain in pregnancy
4. prior macro infant
5. post term
6. glucose intolerance

Question 8

What interventions can be performed in pregnancy to decrease risk of macrosomia?

Answer 8

Exercise
low glycemic diet (in GDM)
control of hyperglycemia
pre-pregnancy bariatric surgery (Class II/III obesities)

Question 9

Regarding macrosomia, what are the maternal risks?
Fetal risks?

Answer 9

maternal risks of macrosomia: CD, PPH, triple I, OASIS

Fetal: SD, clavicular fracture, brachial plexus injury

Question 10

Patient is diagnosed with non-immune hydros at 24 weeks
Differential diagnosis?

Answer 10

1. Infectious causes: Parvo, CMV, Toxoplasmosis, Syphyllis
2. Alpha that major (homozygous)
3. Cardiac anomalies
4. Aneuploidies (turners)
5. Severe anemia (massing hemorrhage)
6. CCAM of Lung

Question 11

Talk about ParvoB19 and hydrops management

Answer 11

Most women are immune to parvo, but a new infection ca result in fetal effects in 1/3 of cases (vertical tramsisison up to 1/3).

Receptor for B19 is on the RBC –> fetal hydrops

Timing of infection matters. Most severe if occurs early, < 20 weeks

Follow these patient with serial US once maternal infection confirmed (with serology).

If fetal hydrops –> MCA dopplers
Cordocentesis and fetal RBC transfusion may be indicated.
Co manage with MFM

Question 12

Herpes
-work up
-primary diagnosis
- non primary first episode diagnosis
-recurrent infection diagnosis
-management
-vertical transmission risk

Answer 12

work up: check PCR (ideally) and serology (IgG)
-primary: PCR positive, IgG negative
-non primary first episode: PCR positive for HSV1, IgG positive for other type
-recurrent: PCR positive and IgG positive for same type
-mgmt: Valacyclovir 1 gram BID x 7-10 days, if a primary outbreak third tri, can continue daily suppresion as shedding is higher with primary
-vertical trasmission via VD: up to 80%

Question 13

Hepatitis B
Treatment
Route of Delivery
any precautions with delivery
breast feeding?

Answer 13

third trimester: tenofovir if viral load > 200K
Delivery: VD or CD, CD only for OB indications. Does not change VT rate
Precautions: can do invasive procedures (internal monitoring, episiotomy, VAVD)
Breast feeding is safe (hep C also)

Question 14

Hepatitis C
-treatment before prgnancy
-how long after treatment should you be wait unitl conception
-risks of Hep C in pregnancy?

Answer 14

24 week course of ribavirin
-wait 6 months to conceive after treatment due to teratogenicity
-PTD, FGR, cholestasis

Question 15

Parvo:
how do you diagnose?
how do you manage?

Answer 15

1/2 of women have lifetime immunity

1. Monitor for symptoms: flu like myalgia, arthralgia, low fever, slapped face rash (or reticular trunk rash)
2. Check Ab to parvo: IgM + IgG
3. If negative: repeat in 4 weeks
4. If IgM positive –> acute infection, refer to MFM as these patients need serial US And MCA dopplers x 8 weeks
5. Hydrops by MCA doppler: pubs to ID severity of anemia then fetal RBC

Good fetal survival with therapy (80%)

Question 16

CMV:
factoids
how do you diagnose?

Answer 16

Most children in US exposed by age 3

1. Monitor for sx…
   most asx or have fever, pharyngitis, polyarthritis
2. Check Ab to CMV: IgG only
   If negative: repeat in 4 weeks
3. IF positive IgG or 4x titer increase –> CMV diagnosis

Sadly, maternal immunity does not prevent against re-infection with fetal transmission or infection by a new strain with fetal transmission

Question 17

what are fetal effects of CMV
how do they differ from toxoplasmosis?

Answer 17

CMV and toxoplasmosis are similar, like Toxo:
Disease is more severe if infected earlier, however higher vertical transmission later in pregnancy

Congenital CMV: (like toxoplasmosis)
intracranial calficiations
LBW
chorioretiniits
HSM
Anemia
Low IQ

How do you tell Toxo and CMV apart on US?

CMV has microcephaly.

Question 18

First trimester bleeding:
Differential Diagnosis

Answer 18

1. implantation bleeding
2. ectopic
3. SAB
4. Cervicitis or vaginitis
5. molar/GTN
6. other cervical/vaginal etiologies- lacerations, neoplasm, polyp, ectropion

Question 19

Second trimester bleeding:
Differential Diagnosis

Answer 19

1. Cervicitis or vaginitis
2. early cervical dilation
3. PTL
4. abnormal placentantion (previa)
5. placental abruption
6. PPROM
7. IUFD
8. Uterine rupture
9. Labor
10. Ruptured vasa previa (rare)

Question 20

Confirmed PAS…
How do you diagnose PAS?
1) how do you follow her?
2) when do you deliver?
3) would you do amnio before deliver?
4) how and where would you deliver?
5)how do you set this CD up in comparison to a routine CD?
6) how would you counsel her before surgery?
7. Site of hysterectomy

Answer 20

US with findings suggestive such as placenta lakes, loss of placenta/myometrial boundary, thinning or loss of uterine serosa/bladder interface, focal intraplacental masses

1. AFS, steroids, optimize blood count prenatally (Consider adjuvant TXA)
2. TOD at 34-35.6
3. No
4. Deliver at Level III/IV center with NICU and equipped to handle intrapartum hemorrhage
5. Two large bore IV’s, consideration of ureters (stents), cell saver, CM2U, gyn onc avail
6. Counseling regarding blood transfusion and consents, C-Hyst risks as well as percreta risks/injury/repair
7. Hysterotomy above the placenta implantation site. Then leave placenta in situ and then Chyst

Question 21

CD on a patient with an anterior placenta previa..
What should you consider pre-op?
1) what skin incision would make?
2) what uterine incision do you make?
3) what criteria do you use to determine if C hyst necessary?
4) Discuss consideration for blood product replacement
5. When do you deliver a placenta previa (uncomplicated otherwise)

Answer 21

Alway consider that there could be an associated PAS…
which leads you to need to be prepared for PPH (large bore IV’s and CM2-4 units) and possible C-Hyst (kit readily available)
1. Skin incision would be pfannesteil
2. Pre-op US to localize placenta margins, Hysterotomy above the placenta implantation… if placenta indices, fetal anemia can happen due to fetal vessel hemorrhage, deliver immediately
3. C-Hyst should be performed if ongoing bleeding and all fertility sparing measures have been performed (rx/mechanical)
4. Massive transfusion if indicated
5. 36 to 37/6 weeks

Question 22

What is the most important risk factor to PAS?

When is MRI helpful?

Answer 22

presence of placenta previa (present 80% of time in accretes)

Equivocal US findings, posterior placenta location

Question 23

What do you do if you inadvertently discover a PAS at time of CD once uterus is open?

Answer 23

1. Notify team/anesthesia
2. Leave placenta insitu
3. Assess maternal stability, if stable =–> call gyn onc.
   If unstable –> close uterus rapidly, call for extra help, notify family member, give blood, and prepare for a Chyst (supracervical)

If stable and not able to do at that facility, close patient up and send to facility that is able to

Question 24

Immediate PPH
1) etiologies
2) steps to managing
-

Answer 24

Etiologies: uterine atony, retained placenta, lacerations (vaginal/cervical), coagulopathy/DIC, partial uterine inversion)

1) Assess patient stability and blood loss,
2) Identify etiology
3) Notfiy RN/anesthesia/patient of possible emergency
4) Two large Bore IV’s, serial vitals, IV crystalloid, cross match 2 units, labs
5) MOVE PATIENT TO OR
6) repeat exam with assistance
7) fundal massage, bimauanl compression,. pitocin (40 units/liter), repairr lacs, remove placental tissue
8)Uterotonics + TXA
9)Balloon tamponade- Bakri 500 ml or Gauze swabs cornu to cornu or JAda

***if any time she is HD unstable, move to laparotomy, give bloods end for DIC labs

*caution when giving saline for fluid overload. When blood available, start transfusion

Question 25

Who needs an immediate transfusion?

Answer 25

Hemodynamically unstable (HR > 100, SBP < 90, MAP < 70), SOB, dizziness, slow pulses QBL>1500 or hypotension/tachycardia * will also need coagulation factors and platelets (massive transfusion)

Question 26

During PPH, you performed a laparotomy as your patient was becoming unstable, what steps do you use at time of laparotomy to control bleeding?

Answer 26

1. B lynch: 1-Chromic on a large needle 2. O leary suture 3. C hyst 4. UAE only if stable.

Question 27

How do you diagnose delayed PPH? What is on your differential? Treatment of subinvoluted placental site? What if it fails? Treatment of retained products?

Answer 27

24 hours to 12 weeks PP Ddx: infection/endomyometritis, subinovlution of placenta, retained products or clot Treatment: uterotonics. IF fails, D&C (even if no products noted) Treatment: suction D&C with US guidance to decrease risk perforation If endomyometritis...broad spectrum antibiotics (amp/clinda)

Question 28

DIC Etiologies Labs abnormalities Treatment

Answer 28

Etiologies: abruption, severe PPH, pre-e/hellp, AFLD AFE Sepsis Labs: low plts and fibrinogen <200, elevated PT/PTT Treatment: stabilize mom, assess if fetus alive/dead 1.Transfuse with FFP and PRBC 2. Assess fetal status and maternal response. If fetus doing well and mother is well, continue with vaginal delivery 3. In setting of placental abruption/DIC --> CD preferred when VD is not imminent, patient is HD unstable, or DIC! or patient unwilling to accept blood

Question 29

Placental abruption management <34 week 34-36/6

Answer 29

1. < 34 wks and no major bleeding/coagulopathy... steroids and delivery at 37-38 weeks 2. 34-36/6: deliver *can consider expectant mgmt if remain asx

Question 30

G1 delivers at 4600 grams by operative delivery. Called to room 20 min later for 4 cm vaginal mass 1. DDX

Answer 30

1. Hematoma (vaginal, vulvar), incomplete placenta delivery, uterine inversion Vaginal hematoma can expand into para-rectal space (rectal pain) and extend above the recto-vaginal septum... can further expand into retroperitoneal space US can be used to evaluate expanding hematoma (or find arterial hematoma from vaginal branch of uterine artery)

Question 31

An expanding vaginal mass PP? 2. Manage 3. If it continues to expand, now what? 4. Hb drops from 10 to 5... now what? 5. Surgical drainage fails to reveal the source... how would you manage if bleeding continues after repacking after evacuation of hematoma?

Answer 31

2. Conservative management: foley, serial vaginal exam and serial CBC, packing can be helpful (but don't occlude visualization) Avoid opening/exploring area immediately, you won't find local site If vaginal hematoma > 4 cm, may need to be evacuated in OR. Try to find vessel, but likely, you can't then evacuate clot and close in layers. - Vaginal packing x 24 hours -foley 3/4. Oh shit! Notify patient and staff of emergency, send labs, order blood products, if stable get CT abd/pelvis. Consult with vascular or IR. If bleeding into retroperotineum, but stabilizing, serial H/H and serial US to evaluate If patient is stable (relatively normal HB), consider IR embolization of vaginal artery)

Question 32

During CD, hysterotomy extension into the broad ligament. 1. How do you manage 2. How do you ID ureter and protect it? 3. How do you do perform an O leary stitch? 4. PACU blood in the urine, now what do you do?

Answer 32

1. I would first want to identify the ureter: located at the level of the uterine vessels, deep to the cardinal ligaments in the retroperitoneal space 2. If with a surgeon who has this experetise, could open the broad ligament and ID ureter prior to placing hemostatic sutures 3. Urology could place stents by opening the bladder dome and directly place stents 3. Place suture A-P medial of the uterus then through broad ligament avascular area and tied and do a higher stitch as well 4. Examine patient in PACU. Look at foley and asses volume of blood and placement Consider urology/urogyn pre-op Go to OR for cystoscopy IF > 1 cm cystotomy (not near trigone), repair If 1 cm, repair in 1 layer If 3 cm, repair in 3 layers + foley

Question 33

How do you assess the ureteral latency at the time of CD?

Answer 33

1. IV Fluorscein or methylene blue 2. Create cystotomy into bladder dome, monitor UO jets 3. Close bladder in two layers with 3-0 Vicryl running continuous sutures 4. Foley

Question 34

Broad ligament hematoma extension near the hypogastric artery How do you manage?

Answer 34

1. Get help. ask for additional surgeons- vascular, blood products, C-hyst kit, transfuse and apply direct pressure. Waiting for vascular to present

Question 35

Vasa Previa -when to repeat US -Mgmt of persistent Vasa Previa -TOD -When to deliver early?

Answer 35

1) repeat at 32 weeks to check for resolution... But need serial growth US's starting at 24 weeks to ID FGR 2) Admit at 30-34 weeks, steroids, MFM consult, AFS NST daily 3) Deliver at 34-35/6 -Vaginal bleeding, PTL, persistent variables on NST,non reactive NST, PROM, VB with fetal tachycardia/+ KB test

Question 36

Patient with a know marginal previa or consider if no prenatal care and heavy vaginal bleeding 1) how do you manage? 2) what is mode of delivery? 3) what if she has a hx CD?

Answer 36

1. Assess maternal hemodynamic stability and fetal stability, determine if emergent CD is indicated Assess vitals, abdominal exam, SSE (NOT DIGITAL), US to ID site of placenta, look for evidence of retro-placental collection of blood, check fetal position, AFI Labs: CBC, coags, fibrinogen, type and cross match, RH status, KB

Question 37

How do you manage a placenta previa that was bleeding but maternal/fetal status is stable? TOD

Answer 37

Admit to LND and monitor continuously, steroids, tocolytics to get steroids in, rhogam, mag for neuroprotection <32 weeks. Consult MFM If bleeding stops and patient is < 34 weeks and has been stable, can go home. If third bleed--> needs to be admitted TOD: 36-37 weeks IF PAS suspected... then earlier, 34-35/6

Question 38

Placenta previa recommendations outpaitent

Answer 38

1) pelvic rest without placing anything in the vagina or intercourse leading to orgasm, avoid moderate/strenuous exercise, no lifting > 20 lbs OR standing > 4 hrs

Question 39

Maternal dyspnea and coagulopathy... What is the cause?

Answer 39

AFE - most likely

Question 40

Amniotic Fluid Embolism -- when to suspect -cause- explain to patient

Answer 40

1) clinical diagnosis in pregnant or immediate PP with sudden cardiovascular collapse, severe RDS, hypoxemia, DIC 2) due to amniotic fluid and antigenic material entering into maternal circulation causing massive anaphylactic reaction --> activation of complement cascade

Question 41

AFE -phases -treatment

Answer 41

two phases: -heart failure leading to hypoxia and cardigenic pulmonary edema --> cardiac arrest -DIC (80%) of patients Treatment: ABC Notify all staff with code alert Airwary- Oxygen/intubation B- breathing/fetal monitoring CPR if arrest Hemorrhage: IV TXA and massive transfusion- FFP/blood products Hypotension: IV crystalloid, caution overload, pressors ICU- further monitoring Perimortem C/D within 4 min, deliver by 5 min if arrested

Question 42

Mom presents with fever and maternal tachycardia at 26 weeks, not in labor and suspect triple I... what is your management?

Answer 42

rule out other causes of fever if diagnosis still uncertain, consult MFM and discussion amniocentesis to confirm infection. IF positive... start antibiotics and MFM recs reviewed

Question 43

Triple I Diagnosis Antibiotics PCN allergy- minor PCN allergy- severe?

Answer 43

1. maternal fever + fetal tachycardia, leukocytosis, purulent VD Amp/Gent + Clinda if CD Cefazolin/Gent Gent/Clinda or Gent/Vanco

Question 44

How do you manage a patient who is undergoing an IOL? -intrapartum GDMA2 mgmt -PP management

Answer 44

1) take usual long acting insulin the night before (withhold AM dose) 2)IVF with NS at 125 (if POCT < 70, switch to d5NS) 3)Check serum glucose q 2 hours then 1 hour in active labor IF blood glucose > 140, start insulin gtt at 1 unit/hr and titrate to maintain blood glucose < 100 PP GDMA2: done with POCT PP PReDMII: half insulin and check fasting, AC/HS, correction factor for coverage

Question 45

How do you counsel a Pregestational Diabetic for pregnancy complications?

Answer 45

1) increased risk for congenital anomalies, IUFD, FGR, Macrosomia, polyhdramnios 2) assess level of blood sugar control 3) baseline assessment of end-organ disease -ekg -ocular exam -24 hour urine pr/cr

Question 46

CHTN: what is your goal for bP control? What do you consider well controlled cHTNM?

Answer 46

BP less than 140/90

Question 47

Cornual ectopic pregnancy -management -counseling -why is it not safe?

Answer 47

-surgical vs. MTX management... consult MFM. But pick surgical for oral exam (corneal excision vs. hyst) -pre-op type and cross match, large bore IV, consent for hyst, laparoscopy -discuss risks of uterine rupture in subsequent pregnancy -not safe due to hemorrhage risk and uterine rupture

Question 48

Who should be offered Hep A and Hep B vaccine in pregnancy?

Answer 48

Hep B: anyone who isn't vaccinated Hep A: high risk groups (international travelers, occupational risk, homeless, Chronic liver disease, HIV, anyone who requests it

Question 49

Herpes Vertical Transmission Risk Primary Non primary, 1st episode Recurrent infection

Answer 49

up to 80% 33% 3%