Monday 4/27/2020

Pre-labor Rupture of Membrane (PROM)

Rupture of the amniotic membranes before the onset of labor. This patient is beyond 37 weeks gestation and presents with rupture of membrane. This rupture can lead to a few possible complications such as endometritis or chorioamnionitis if prolonged more than 24 hrs.

Risk factors: STI’s, smoking, prior preterm delivery and multiple gestations.

Signs/Symptoms: Gush of fluid or persistent leakage of fluid from the vagina.

Diagnosis: Sterile speculum exam: where we can see pooling of secretions in posterior fornix upon inspection. If pooling is not seen but you are still suspicious then ultrasound is recommended to assess amniotic fluid volume. Once visualized, obtain the fluid for culture and use a nitrazine paper or fern test to test it. If the Nitrazine paper turns blue that means the pH is more than 6.5 which most likely indicates that PROM has most likely occur because normal amniotic fluid has a pH of 7 and the vagina has a pH of around 4. In the fern test, the amniotic fluid is allowed to dry for 10 mins on a glass slide and is viewed under a low-power microscope which if positive we will be able to see a ferning pattern which is the crystallization of estrogen and amniotic fluid.

It is recommended to avoid digital vaginal examination. This is because we want to avoid any risks of possible infections.

Management: Admit the patient with fetal monitoring and await for spontaneous labor. The majority of these patients will go into spontaneous labor within 24hrs after PROM. While waiting for spontaneous labor, monitor for infections such as endometritis or chorioamnionitis.

If spontaneous labor does not occur within the next 18hrs then we can labor induce with prostaglandin cervical gel or Oxytocin.

We can also give antibiotics if infection is present such as IV ampicillin.

Pre-term pre-labor rupture of membranes (PPROM)

Rupture of the amniotic membrane before the onset of labor occurring prior to 37 weeks.

Complications: Same as PROM (endometritis or chorioamnionitis if prolonged more than 24 hrs).

Risk factors: STI, smoking, prior preterm delivery, multiple gestations.

Signs/Symptoms: Just like in PROM, there is a gush of fluid from vagina. However there are times when women may experience only small amounts of fluids and a sensation of abnormal wetness of the vagina.

Management:

If no signs of maternal or fetal infection or distress, admit the patient with fetal monitoring an await for spontaneous labor. The fetus is at a greater risk of PPROM mortality than the mother.

If under 34 weeks then you should administer corticosteroids such as betamethasone to enhance fetal lung maturity. You can do amniocentesis to assess for lung maturity. While giving betamethasone, you can also give tocolytics to the patient to delay delivery for 48hrs and allow for betamethasone to work better. This is all done when you are sure there is no signs of chorioamnionitis or other infections.

Can also give antibiotics such as ampicillin with azithromycin to prevent potential infections.

Only do prompt delivery if there is sign of fetal/maternal infection or distress.

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Wednesday 04/29/2020

Ovarian Torsion

Ovarian torsion refers to the complete or partial torsion of ovary on its ligamentous supports, compromising ovarian blood flow which can lead to ischemia and infraction. Its considered one of the most common gynecologic surgical emergencies and effects women of all ages. The fallopian tubes often twist along with the ovary and when this occurs it’s called adnexal torsion.

Ovarian cysts or ovarian neoplasms can also increase the chance of ovarian torsions. As the mass of these cysts or cancers increases, the higher the chance for the ovary to rotate on its axis of the infundibulopelvic and utero-ovarian ligament and become fixed in a torsed position.

The right ovary appears to be more likely to be torse than the left, possibly due to the reason that right utero-ovarian ligament is longer than the left and also the presence of sigmoid colon in the left side of the colon may help to prevent ovarian torsion on that side.

Complete occlusion of the ovarian blood supply will eventually result in loss of ovarian function and necrosis of the torsed tissues. If no intervention occurs then chronic adnexal torsion can also occur as well.

Clinical presentation:

Unilateral pelvic pain which is usually acute

Nausea and vomiting may be associated with pain.

In rare cases, fever may also be a sign however it there is fever we have to think of adnexal necrosis as well.

On physical exam, these patients will also be positive for abdominal tenderness and adnexal mass felt upon palpation.

Diagnosis:

Pregnancy test (serum HCG) should be done to rule out pregnancy and ectopic pregnancy.

Ultrasound with doppler- initial test of choice which can show decreased ovarian blood flow (ovaries have a dual blood supply). However normal flow does not exclude torsion so definite diagnosis is made during surgical exploration.

Management:

Laparoscopy with detorsion is indicated to restore blood flow.

Ovarian cystectomy may be needed to remove the responsible cyst and preserve the ovary in premenopausal women.

Stages of Labor:

First stage of labor: Thinning (effacement) and opening (dilation) of the cervix. As your cervix dilates, your health care provider will measure the opening in centimeters. During this stage, your cervix will dilate up to 10 centimeters. This first stage of labor usually lasts about 12 to 13 hours for a first baby, and 7 to 8 hours for a second child.

Early. Early contractions are usually irregular, and they usually last less than a minute. The early phase of labor can be uncomfortable and may last from a few hours to days.

Active. Contractions become strong and regular. Usually lasts 3–5 hours with regular contractions that happen every 3–5 minutes. This is the time to go to the hospital or birthing center. The pain of contractions may be moderate or intense.

Transition. Which usually lasts 30 minutes to 2 hours with very intense contractions that happen with only 30 seconds to 2 minutes of rest. The cervix will open completely. If there are no problems, the baby should be in position to be born. Some women will shake and may vomit during this stage and this is normal. The amniotic sac may rupture at any point during these phases.

Stage two. (pushing stage) The cervix is dilated completely and the baby is born. We also have the 3 P’s here: Power (forceful contractions), Passenger (fetus) and Passage (boney pelvis). The fetus is fully flexed with flexed arms and legs. Those that are not completely flexed have a harder time making thru the passage. The optimal position would be vertex cephalic position of the fetus which includes flexion of the head as well. In this stage there is also cardinal movements of the fetus) After the feta; head passes the symphysis pubis there is head extension. Anterior shoulder slips under the symphysis pubis which follows by the posterior shoulder. This stage can last three or more hours. The length of this stage is dependent upon the positioning of the mother (upright = faster), the positioning of the baby and whether medications have been used.

Stage three. This stage occurs after the baby is born. You have contractions until the placenta is delivered. The placenta should be carefully removed and make sure there is no placenta left behind. 30 mins.

Stage four. This is the first few hours after the birth. Major physiological changes such as adaptation to the blood loss and uterine involution (uterus is transformed from pregnant to non-pregnant state).

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Friday 05/1/2020

Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172436/pdf/pmed.1001733.pdf

Key points:

• This randomized controlled study was conducted in four sub-Saharan countries, however it followed guidelines set up by WHO.
• Three-arm trials were conducted to compare two-dose mefloquine with two-dose sulfadoxine-pyrimethamine.
• The three trials were: 1) Preventative treatment in pregnancy with sulfadoxine-pyrimethamine, 2) Preventative treatment in pregnancy with mefloquine (15mg/kg full dose) and 3) Preventative treatment in pregnancy with mefloquine (15 mg/kg split dose over 2 days).
• 4,749 pregnant women who lived in the sub-Saharan region, where exposure to malaria is high, were randomized to receive preventative treatment. 1,578 of them received sulfadoxine-pyrimethamine, 1,580 received mefloquine full dose and 1,591 received mefloquine at split dose.
• When it came to reducing low birth weight, there was no significant differences between those patients who took mefloquine and those who took sulfadoxine-pyrimethamine.
• The risk of maternal peripheral malaria parasitemia during delivery was 30% lower in women who received mefloquine when compared to those who received sulfadoxine-pyrimethamine.
• The risk and frequency of maternal anemia was also lower in those patients who received mefloquine when compared to those who received sulfadoxine-pyrimethamine.
• There was no significant difference between the two treatments when it came to placental infection, neonatal parasitemia, neonatal anemia, or maternal peripheral parasitemia.
• Number of clinical malaria episodes during pregnancy were significantly lower in women who received mefloquine than those women who received sulfadoxine-pyrimethamine.
• When it came to adverse effects and adverse pregnancy outcomes such as: miscarriages, stillbirths or congenital malformations, there was no significant difference between the two preventative treatments.
• There was no significant difference between patients who took mefloquine as a full dose and those who took mefloquine as a split dose in all the categories mentioned above.
• When it came to tolerability, those patients who took mefloquine showed a poorer tolerability in both full and split doses than patients who took sulfadoxine-pyrimethamine.

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