QnA sample for OBGYN HO assessment

GDM - Gestational Diabetes Mellitus

• when to diagnose gdm ?
• risk factor
• when to check mogtt x1 and x2
• how do you know bsp controlled ? - check hba1c also
• when to induce if GDM d/c and GDM on meds ? ( at how weeks )
• how to start s/c insulin in GDM if needed , and how many unit ?

HTN - Hypertension

• when to diagnose gestational hypertension ?
• when to start antihypertensive in gestational hypertension ?
• when to induce ? ( at how many weeks  of gestation)
• which antihypertensive meds to start first ? 
• Methyldopa
• Labetolol
• Nifedipine 

when you consider it as Preeclampsia?

what are the next step of managements?

what to do if the patient is fitting?

NVP - Nausea and Vomiting in Pregnancy

• What indicator show that we need to admit this patient if she come with NVP ?
• how to ddx with hyperemesis gravidarum
• If urine ketone positive
• How many pints to hydrate patient with NVP ?
• investigations to take?

Miscarriage 

• How to diagnose
• types of miscarriage
• Scan findings in miscarriage
• ET thickness and its relation to status of pregnancy

PPH - Post Partum Haemorrhage

• How to Dx, Mx
• Ddx PPH
• Meds to use if Pitocin already max 80u
• How many time can use Hemabate
• What to do if all med fail

Shoulder dystocia

• What Method, when to do it?
• How to do Mc Robert
• What are the HELPPER
• If all fail what to do

Referral template to paeds - from OBGYN HO prespective

HUSM obgyn paeds referral template:just a note for me to remember when needed to be used. 

This template is also being passed down by seniors, grateful to those who started this. 

It is too common that we are being scolded for not presenting detail enough while referring case to MO paeds. This will be especially useful for those who are like me, went to OBGYN posting first before paeds, and have no idea what to do. 

Good luck guys!

It is part malay and english, so those who dont understand malay it's time to pick up a new language. 

**especially those who graduated oversea. 

Paeds referral

Summary:

Dr, saya HO(houseman) xxx, from LR(labor room)/ward xx nak refer baby of 

(example of problems)

i. M(maternal) GDM on insulin/metformin

ii. M PROM > ? hrs

iii. M GBS positive

iv. Macrosomic baby (> 4.5kg)

v. Low birth weight baby (<2.5kg)

(Example notes to write in record)

This is baby of ___.

Baby boy/girl, currently _ hours of life. 

Born via SVD at _weeks __days POA(period of amenorrhea)/POG(period of gestation) 

with BW(birth weight) _kg & Apgar score __ at 1 min 

Antenatally mother have

1.

2.

3.

4. 

On examination of baby

- Baby pink, active on handling

- Anterior fontanelle normotensive

- Good sucking

- Lungs clear, RR?, no grunting, no nasal flaring

- CVS S1 S2 heard, HR?

- PA soft, 2A1V

- Male/female genitalia normal. Bilateral testes descended (if male), anus patent

- No DDH, good palmar grasp

- Spine Normal

- Moro complete. 

Some details to take note for each case:

1. Low birth weight(LBW) baby

• LBW<2.5kg
• VLBW <1.5 (V: very)
• ELBW <1kg (E: extreme)

*Not all LBW are SGA (Small Gestational Age)

*It can be AGA (Appropriate for Gestational Age)

So plot growth chart if has LBW baby

SGA : wt <10th centile

Symmetrical SGA : all components <10th centile

Asymmetrical SGA : wt (weight) <10th centile, COH (circumference of head) and length almost achieve centile for the gestational age 

2. Infant diabetic mother

Screen for diabetic embryopathy

1. mention types of medication used

- are they on Insulin? 

• type of insulin? actrapid / insulatard
• what is the total dose per day
• when they start?
• is their BSP (blood sugar profile) optimised?

2. Please mention Hba1c: indicates control 

• (if possible mention early pregnancy HbA1c and late pregnancy values)

3. BSL (Blood Sugar Level) of baby at 1 hr

• If refer at 4 hours of life, at least have 2 BSL. If hypoglycemic after feeding refer immediately to MO paeds. 

3. Infant of hyperthyroid mother

• Please know latest TSH, T4 and Medications of mother
• Heart rate of child 

4. Infant risk of sepsis

(PROM, PPROM, UTI(urinary tract infection)) 

UTI

1. If UTI please mention when they got UTI

• inform the UFEME results
• inform urine C+S if available

2.  Any Antibiotic coverage?

• types of antibiotic
• dosage
• given how many times
• since when
• any temperature spike or signs of sepsis in mother

PROM/PPROM

(premature rupture of membrane). preterm premature rupture of membrane

• Please know duration of leaking

• >12hrs? / >24hrs?

• Doses of antibiotics?

            - last dose bila , how many of hour before delivery

            - any chorioamnionitis signs?

            - liquor?

• post delivery baby mcm mana?

• Mother

• FBC: Hb, WBC, PLT

• HVS C+S (high vaginal swap culture and sensitivity)

reference:

1. https://myhow.files.wordpress.com/2013/11/hoguidepeds1.pdf

Induction of labor - Obstetric

 

Here is the summary of IOL and more information do scroll down to understand further details. 

Notes:

• IOL : Induction Of Labor
• GDM: Gestational Diabetes Mellitus
• PROM: Premature Rupture of Membrane
• IUD: Intrauterine Death
• IUGR: Intrauterine Growth Restriction
• LGA: Large Gestational Age
• NRVE: Next Review Vaginal Examination
• NRC: Next Review Contraction
• LSCS: lower segment caesarean Section

Bishop score

Balloon Device

Inflated bulb of a Foley catheter exerts pressure to the internal os of the cervix which then stretches the lower uterine segment and stimulates release of prostaglandin (PG)

Contraindicated in patients with low-lying placenta

The catheter is left in place until it falls out spontaneously/24 hours have elapsed

Pharmacological approach

Artificial Rupture of Membrane

- one of the ways of induction of labor (IOL), usually to speed up the process of labor

- only been done when cervix is dilated to >4cm or > 3cm if indicated

- and baby's head firmly decended to the pelvis.

Contraindication:

1. Bishop score<6

2. breech

3. grandmultipara

4. preterm

5. high presenting head

6. polyhydramnious - if rupture is needed: need to have controlled ARM

    - where assistant is needed to control the baby's position to avoid baby from changing position

Risk: 

1. cord prolapse: if the baby head is not engaged well, and membrane rupture causing the cord to slip down below the baby's head.

2. Sepsis: when the labor time is prolonged

3. Failure of induction

4. increase risk of fetal distress

Before you start ARM procedure, always remember to check 

• Patient's name, and registration number
• confirm Antenatal history
• Are they indicated for ARM?
• or any contraindications
• check if any oligohydramnious / polyhydramnious - as baby could change position if not stabilised
• How is the position of the mother and Baby?
• Ensure there is an IV line set already with IV drip

• Vaginal Examination: any cord/ placenta
• Cx and Os dilation, Station
•  Ensure mother is not having contraction when you wanted to rupture the membrane
• only rupture when there is no contraction 
•  to avoid causing chorioamnionitis (acute inflammation of the membranes and chorion of the placenta, typically due to ascending polymicrobial bacterial infection in the setting of membrane rupture.)

    

Post ARM

• monitor mother's 
• vital sign
• contraction
• progress of labor 
• Vaginal examination 4hrly. 
• time contraction (NextReview of Contraction): 2hrly 
• baby's fetal heart rate

References: 

1. https://www.moh.gov.my/moh/resources/auto%20download%20images/587f135ba2e92.pdf

AUB

Abnormal uterine bleeding

One of the most common disease in gynae ward

Definition 

- infrequent episode of bleeding(oligomenorrhea)

- prolong duration of menses (longer than 7 days)

-  excessive flow of menses (soaking>1 every 1-2hr, passing blood clot>50cents, soak pads for >2-3hrs in a row)

- coital bleeding

- intermenstrual bleeding

Risk factor: 

Palm coin mneumonic

Mx:

- make sure you asked the menstrual history throughly, it would aid in differential diagnosis and approach. 

• age
• cycle length
• duration of bleeding
• flow: heavy, medium, light
• any contraceptive use? 
• when is the last mentrual date (LMP)
• any dysmenorrhea
• any abortion done before/ miscarriage/ last SI(sexual intercourse)
• hx of anemia/ 
• any family hx of cancer/ social hx/ past medical hx

1. v/s

- BP (low?),

- PR(tachy?)

- temperature

- SPO2

- physical examination: pallor? bruising?

2. Set up

- call for help

- 2 large bore IV branulla

- GXM 2pint standby

- send FBC, coag, 

- O2 supply

- pelvic ultrasound

3. ensure hemodynamicallly stable

- IVD run fast (hartman+NS)

- T. tranxenamic acid

- IV tranxenamic acid

- if its retained products of conception: attempt to remove if possible (D+C), if unable, arrange for ERPOC

- pregnancy test if possible. 

Specific treatment once pt is stable:

reference:

1. https://www.researchgate.net/figure/FIGO-classification-of-causes-of-AUB-PALM-COEIN_fig1_284797278

Common meds used in OBGYN

Common medications seen during OBGYN posting

Supp voltaren 100mg BD

IV pitocin 40u in 1pint NS/6-8h 

IV ampicillin 500mg QID

(prom: ampicillin 1g stat and 500mg QID@12hrs post prom) 

s/c heparin 5000u BD 6hr after op 

IV cefuroxime 750mg TDS 

IV flagyl 500mg TDS 

IV transxenamic acid 1g TDS 

Pain management

C. Celebrex 200mg BD

T. Pcm 1g QID 

IV tramal 50mg start 

Pre-operation meds

IV ampicillin 1g stat to OT

IV maxolon 10mg stat to OT

IV ranitidine 50mg stat to ot

Mist sodium citrate 30cc stat to ot

Iv cefuroxime 1.5g start to OT (on request) 

Post natal

I'm symtometrine 1ampule (before placenta delivery) 

Iv pitocin 40u/6hrs

T pcm 1g PRN

PPROM : 

T. EES 400mg BD x10/7 

If mum rhesus negative :IM volgram/rhogam at 28w and 34w 

For PROM

>18h? - IV Benzylpenicillim 3g stat & 1.5g 4hourly 

or 

IV Ampicillin 1g stat(some gave 2g stat based on the duration of leaking)

Preterm tocolysis

- nifedipine 20mg stat & 10mg x3 with 15 mins interval & 10mg TDS x 48h.

+ MgSO4 bolus & infusion (depends on hours) for neuroprotection 

Bricanyl 0.25mg during hyperstimulation/asthma

Pt allergic to penicillin alternatives

- IV clindamycin 900mg TDS 

- IV cephazolin 1g TDS x 2/7 & tab EES 1g stat, then change to tab cephalexin 500mg QID x 5/7

- IV cephazolin 2g loading dose, then IV cephazolin 1g TDS 

PPH 

IV pitocin 10u/40u /80u (max)

IV pitocin 5u/10u bolus

IM hemabate 1ampule stat

IM symtometrine 1 ampule stat