UMEM Educational Pearls - Obstetrics & Gynecology

Bacterial Vaginosis

1. The most common vaginal infection in childbearing women. 
2. Associated with burning, itching, and malodorous discharge.
3. Cause is not fully understood but associated with
   
   1. douching
   2. multiple sexual partners.
4. Complications caused by BV
   
   1. Increased susceptibility to HIV, HSV, chlamydia and gonnorrhea
   2. Increased risk for preterm labor.
   3. Increases the chance of an HIV woman passing HIV to her sex partner.
5. Woman at high risk for preterm delivery should be tested for and treated for BV, however, the US Preventive Services Task Force just released a statement discouraging testing in woman at low risk for preterm delivery. 
6. Treatment options include metronidazole and clindamycin.

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Ultrasound in Pregnancy

1.  A full bladder is needed for Transabdominal Ultrasound and an empty bladder for transvaginal ultrasound.
2. A gestational sac should be visible on transabdominal ultrasound with a quantative HcG of 5000-6000 mIU/ml, and a quant of 1500-2000 mIU/ml on transvaginal.
3. When taking photos, ensure that you show all of the applicable landmarks.  [i.e.: bladder, and uterus]  If you just zoom in on the pregnancy anybody else (i.e.: your expert witness) reading the scan will not be able to confirm that the pregnancy is in the uterus.
4. To confirm an IUP, you must see the yolk sac within the gestational sac.  A double decidual sign is an early sign of pregnancy but it is not always seen and should not be relied upon.
5. If you have a confirmed IUP an additional ectopic pregnancy is extremely unlikely unless the patient was taking medication to stimulate their ovaries (i.e. Infertility treatment).  If on stimulation therapy a very thorough exam needs to be done to look for additional pregnancies.
6. If Quant >2000 mIU/ml and there is no evidence of an IUP, patient needs to be treated as an ectopic pregnancy.

Rhogam 

• Remember to administer Rhogam to any Rh negative mother that has the following conditions:
• Pregnancy/delivery of an Rh-positive baby
• Abortion/threatened abortion at any stage of gestation
• Ectopic pregnancy
• Antepartum fetal-maternal hemorrhage (suspected or proven) resulting from antepartum hemorrhage (e.g., placenta previa), amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling, other obstetrical manipulative procedure (e.g., version) or abdominal trauma
• Transfusion of Rh incompatible blood or blood products (i.e.: platelets)

Dosing:

• 300 mcg IM
• Can give 50 mcg IM within 72 h of exposure of a therapeutic or spontaneous abortion if gestation age is 12 weeks or less. (Order as MICRhogam)
• Additional doses of Rhogam may be necessary when the patient has been exposed to > 15 mL of Rh-positive red blood cells. This may be determined by use of qualitative or quantitative tests for fetal maternal hemnorrhage but generally will only occur during a full term delivery or if incompatible blood products are given.

 

Trivial Fact: Rhogam is Pregnancy Class C

Migraines and Pregnancy

• Typically headache frequency will increase during the first 2 to 3 months of pregnancy
• 70% of women report significant improvement in headaches during their second and third trimester.
• Most migraine medication should NOT be given to pregnant woman.  Verify prior to prescribing.
  • Class X/D drugs include
    • Cafergot (ergotamine)
    • Depakote
    • Dihydroergotamine (DHE)
  • Class C drugs include
    • Imitrex
    • Zomig
    • Midrin
    • Relapex
• Some headache centers will prophalax pregnant woman with Vitamin B2 and Magnesium.

 

Placental Abruption

• Leading cause of fetal death (1-80 pregnancy)
• Evaluation
  • Ultrasound has very poor sensitivity
• Can check D-Dimer, Coags, Fibrinogen and Fibrin Split Products
• For a stable patient MRI can make diagnosis.
• Fetal monitoring (minimum four hours) where fetal distress and uterine contractions are seen.
• Risk factors for Placental Abruption
  • Hypertension
  • Pre-eclampsia
  • Diabetes
  • Trauma
  • Smoking
  • Cocaine
  • Advanced maternal age
• Treatment
  • C-Section

If you are facing the imminent delivery of a newborn with shoulder dystocia remember the mnemonic HELPERR. * Help. Call for it. * Episiotomy. o Necessary only to make more room if rotation maneuvers are required. * Legs (the McRoberts maneuver) o This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. * Pressure, Suprapubic o The hand of an assistant should be placed suprapubically over the fetal anterior shoulder, applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the fetal shoulder. This maneuver should be attempted while continuing downward traction. * Enter maneuvers (internal rotation) o Attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis. * Remove o Remove the posterior arm. * Roll the patient. o Rolling the patient on all-fours will often dislodge the shoulder, and the position change allows gravity to aid in the disimpaction of shoulder. Baxley EG, Gobbo RW. Shoulder Dystocia, Am FamPhysician. 2004;69(7):1709-1714.

The best known peripartum complications are pre-eclampsia and eclampsia. However, do not forget about HELLP syndrome which occurs in approximately 0.2 to 0.6 percent of all pregnancies. HELLP is an acronym for: Hemolysis Elevated Liver Enzymes Low Platelet Treatment consists: 1. Seizure prophylaxis with magnesium 2. Blood pressure control 3. Corticosteriods and plasmapheresis may be helpful in severe causes 4. Supportive care. 5. Early delivery of child.

In follow up to my Shoulder Dystocia Pearl

Dr. DePriest Whye has some legal pearls for us:

Erbs Palsy( Brachial Plexus Injury) is a known complication of shoulder dystocia and is due to traction on the arm that causes stretching of the brachial plexus.

• Should an Erb's Palsy result as a consequence of a shoulder dystocia, a medical malpractice suit is inevitable.
• The medical record documentation is particularly critical in defending the medical care rendered.
• The medical record should reflect timely recognition of the shoulder dystocia.
• It is important that appropriate implementation of the maneuvers described last week are done in a timely fashion.
• Vital documentation should describe the amount of traction placed if any.
• Terms such as minimal or mild or light traction should be used.
• Terms such as strong, forceful, significant traction should be avoided.
• Never state in the record that uterine pressure was used as opposed to suprapubic pressure.
• Uterine pressure is contraindicated.

Erb's Palsy cases are difficult to defend. They are impossible to defend with improper documentation.