Missed OB Qs

1. Patients with HELLP syndrome should be managed according to length of gestation and disease severity. Patients symptomatic with headaches or abdominal pain with elevated liver enzymes should undergo immediate induction of labor if they are greater than 33 weeks gestation.
2. The stepwise approach to uterine atony includes: Uterine massage with oxytocin, Methylergonovine, prostin (PGF2), dilation and curettage, exploratory laparotomy, and hysterectomy.
3. Dyspnea of pregnancy is a common occurrence most commonly due to decreased Paco2 levels, resulting from a 30 – 40% increase in tidal volume.
1. Decreases in total lung capacity or increases in tidal volume can also contribute to this problem,
4. Intrahepatic cholestasis of pregnancy presents with pruritus and jaundice in the third trimester. Elevated bile salts confirm the diagnosis.
1. The most common cause of pruritus in the third trimester of pregnancy is intrahepatic cholestasis of pregnancy. It presents with generalized pruritus and signs of biliary obstruction (jaundice or icteric sclera). Increased circulating bile salts confirm the diagnosis. Elevated liver enzymes are generally not a feature
5. Symptomatic abnormal uterine bleeding should be treated with IV estrogen followed by admission to the hospital with subsequent D&C.
6. Maternal exposure to DES should be suspected in patients with incompetent cervix who have a history of recurrent painless spontaneous abortions.
1. In utero exposure to DES carries a high association with the future development of clear cell adenocarcinoma of the vagina.
7. Abortions occur before 20-weeks gestation. Know how to differentiate between the types based on bleeding, cervical dilation and loss of products of conception.
8. The management for inevitable abortion is emergent dilation and curettage.
9. When the hCG is below threshold for identifying an intrauterine pregnancy in a stable patient repeating the measurement in 48-hours is most appropriate.
1. The threshold for a transvaginal ultrasound is about 1500mIU/mL.
2. A rise of hCG of at least 65% after 48-hours is a good indication that the pregnancy is normal.
3. A plateau in hCG over 48-hours indicates a non-viable pregnancy but it still doesn’t identify the location. Transvaginal ultrasound is more sensitive than transabdominal
10. The most likely explanation for not being able to see the string of an IUD is that it has fallen out or it has moved into the uterine cavity. Because the next step is exploring the endocervix which could compromise a growing fetus you should always perform a pregnancy test first.
11. The management for PPROM complicated by infection is vaginal delivery as soon as possible.
1. There is a high risk of infection 18-hours after rupture of membranes.
2. The fetus is at high risk for a serious infection thus labor should be induced as soon as possible regardless of fetal lung maturity