Nonstress test and biophysical profile mnemonic video notes

Video notes

Nonstress test: Measure the heart rate of the fetus in response to its own movements

Very easy to perform using a doppler.

The definition currently recommended by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics (2007) is:

- Two or more accelerations of FHR
- Occurring within 20 minutes of beginning the test
- Acceleration should peak at 15 bpm or more above baseline
- Should last 15 seconds or more,

Assesses fetal well being.

Accelerations with or without fetal movements be accepted, and that a 40-minute or longer tracing—
to account for fetal sleep cycles—should be performed before concluding that there was insufficient fetal reactivity.

VAS (Vibroacoustic stimualtion): Vibratory sound stimulus to induce FHR accelerations.

Biophysical profile:
Sonography machine and Doppler ultrasound to record fetal heart rate.
Typically, these tests require 30 to 60 minutes of examiner time.

Five biophysical components assessed.

Normal variables are assigned a score of 2 each and abnormal variables, a score of 0.
Thus, the highest score possible for a normal fetus is 10.

Fetal breathing: > 1 episode of rhythmic breathing lasting > 30 sec within 30 min
Amnionic fluid volume: A pocket of amnionic fluid that measures at least 2 cm in two planes perpendicular to each other (2 x 2 cm pocket)

Fetal tone: 1 episode of extremity extension and subsequent return to flexion

Fetal movements: 3 discrete body or limb movements within 30 min
Fetal heart rate acceleration: > 2 accelerations of  > 15 beats/min for > 15 sec within 20–40 min

That's all!

-IkaN

Oxytocin

OXYTOCIN

Hello Awesomites! Here's a collection of important facts about the love hormone oxytocin.

Oxytocin sensitivity is increased during delivery.

In lactating women genital stimulation enhances oxytocin release.

Oxytocin challenge test for assessing fetal well being is contraindicated in - Placenta previa
Previous two LSCS
Premature labour

Posterior pituitary secretes Oxytocin.

Oxytocin causes Milk ejection, Contraction of uterine muscle & Myoepithelial cell contraction.

Post partum hemorrhage, Uterine inertia & Breast engorgment due to inefficient milk ejection reflex are indication for oxytocin.

Side effect of oxytocin are Placental abruption, Fetal distress & Water intoxication.

Oxytocin is synthesized in Hypothalamus.

Oxytocin is a Polypeptide.

Oxytocin is Secreted in both sexes.

Oxytocin is an example of neurohormone.

Atosiban is an Oxytocin antagonist.

-MD Mobarak Hussain (Maahii)

Menopause

Menopause : Facts

Gonadotrophins remain elevated after menopause for rest of life.

Average age range of attaining menopause is 45 - 55 years.

A 35 years old lady is not having her menses for last 4 months. She has high serum FSH and LH level with low estradiol. The likely cause is Premature menopause.

Predisposing factors for endometrial carcinoma is late menopause.

Carcinoma vulva is seen in seen after menopause and viral predisposition.

There may be an increase in FSH secretion by the pituitary gland in menopause.

Systemic vasomotor instability may be present in menopause.

There is a decrease in skin elasticity after menopause.

The symptoms of menopause are best treated with Estrogen.

Late menopause is risk factor for breast cancer.

Osteoporosis is seen in menopause High progesterone, High estrogen & Low FSH are seen in menopause.

Menopause may cause prolapse of cervix.

-MD Mobarak Hussain (Maahii)

Magnesium sulphate in management of pre-eclampsia (dosing)

Dosing of magnesium sulphate in management of pre-eclampsia

Using magnesium sulphate as a neuroprotective agent against seizures is a well known fact. We have been taught to follow Pritchard's regimen all through medical school, but actually dealing with it in the labour ward is a whole other scenario!

In the Indian setup (especially a government setup), magnesium sulphate is not always found in the concentration it is to be administered.

USMLE Step 3 CCS: Rape

Hello!

These are my CCS steps for a case of rape. Lemme know if I missed out on anything!

Consent
Rape evidence kit

Complete physical examination

CBC
BMP
Vaginal fluid analysis
Vaginal, cervical, rectal cultures
BHCG
UA
Urine culture
HIV test, P24 antigen
VDRL
HbSAg
Gonococcal tests
Chlamydial tests

Emergency contraception (ulipristal / levonogestrol)
Ceftriaxone
Azithromycin
Metronidazole
Tenofovoir + emtricitabine + raltegravir
HBIG (if unvaccinated)

Psych consult
Drug screen
Colposcopy (for injuries)

That's all!
-IkaN

Puerperal sepsis

PUERPERAL SEPSIS

Puerperal sepsis is any bacterial infection of the genital tract which occurs after the birth of a baby. It is usually more than 24 hours after delivery before the symptoms and signs appear.

Some of the most common bacteria are:
Streptococci
Staphylococci
Escherichia coli (E.coli)
Clostridium tetani
Clostridium welchii
Chlamydia
Gonococci

SYMPTOMS AND SIGNS 
Fever (temperature of 38°C or more)  Chills and general malaise
Lower abdominal pain
Tender uterus
Subinvolution of the uterus
Purulent, foul-smelling lochia.
Slight vaginal bleeding
Shock.

RISK FACTORS
Some women are more vulnerable to puerperal sepsis, including anaemia and/or malnourished, protracted labour, prolonged rupture of the membranes, frequent vaginal examinations, a traumatic delivery, caesarean section and retained placental fragments, PPH, diabetes all predispose to puerperal infection.

SITES
The most common site of infection in puerperal sepsis is the placental site.
Other sites of infection are abdominal and perineal wounds following surgery and lacerations of the genital tract, e.g. cervix, vagina and perineum.

Following delivery, puerperal sepsis may be localized in the perineum, vagina, cervix or uterus.
Infection of the uterus can spread rapidly if due to virulent organisms, or if the mother’s resistance is impaired.
It can extend beyond the uterus to involve the fallopian tubes and ovaries, to the pelvic cellular tissue causing parametritis , to the pelvic peritoneum, causing peritonitis , and into the blood stream causing septicaemia

DIFFERENTIAL DIAGNOSIS
Fever  in the puerperium can also be caused by:  urinary tract infection (acute pyelonephritis)  wound infection (e.g. scar of caesarean section)  mastitis or breast abscess  thrombo-embolic disorders, e.g. thrombophlebitis or deep vein thrombosis  respiratory tract infections.

-Md Mobarak Hussain (Maahii)

Fact of the day : Easier approach shot to the pouch of Douglas

Hey Awesomites

The posterior fornix of the vagina is separated from the peritoneal cavity by a single layer of peritoneum and the posterior vaginal wall. Therefore, vaginal approach from its posterior aspect for evacuation of pus in the pouch of Douglas can be done without much difficulty.

On the other hand, approach to uterovesical pouch ( anterior relation ) is much more difficult from the vaginal route and consists of a series of steps :
- Incise the vagina
- separate bladder from cervix
- Traverse the vesicocervical space ( till the uterovesical fold of peritoneum is reached )

This difference is due to the normal physiological position of the uterus that is anteverted and anteflexed; the direction of external os being downwards and backwards.


That's all
- Jaskunwar Singh

USMLE Step 3: CCS pregnancy case checklist

Hello!

Here are things to do for a CCS pregnancy case -

Image Based MCQ on Twin Pregnancy

Hello awesomites! 

Yesterday we posted an Image based MCQ on Twin Pregnancy. Here's the answer for it. 

#Radiology
#Obs_Gynae
Q. What is the diagnosis of the given USG image? 

A. Polyhydramnios 

B. Diamniotic Monochorionic twins 

C. Diamniotic dichorionic twins

D. Monoamniotic Monochorionic twins. 

The correct answer is C. Diamniotic dichorionic twins. 

The twin peak sign (also known as the lambda (λ) sign) is a triangular appearance of the chorion insinuating between the layers of the inter twin membrane  and strongly suggests a dichorionic pregnancy.  It is best seen in the first trimester (between 10-14 weeks). While the presence of a twin peak sign is a useful indicator of dichorionicity its absence, however, is not that useful in confidently excluding it.

It should be noted that the 'twin' in 'twin-peak' refers not to the presence of two peaks, but that it relates to twins. In pregnancies with more than two fetuses, the chorionicity and amnionicity of the each fetus may be different, and therefore this sign only aids in determining chorionicity of adjacent twins.

That's all! 

Thank you 

MD Mobarak Hussain (Maahii) 

Image Based MCQ on Shoulder Dystocia

Hello awesomites!
Yesterday we posted an Image based MCQ on Shoulder Dystocia.
And as promised here is the answer.

#Obs_Gynae
Q. The image given below represents:

A. Mc Roberts maneuver
B. Woods corkscrew maneuver
C. Cleidotomy
D. Zavanelli maneuver

The correct answer is A.

The given image shows Mc Roberts maneuver.

All of the above mentioned maneuvers are used for management of shoulder dystocia.

Mc Roberts maneuver:
In this maneuver, legs of the mother will be abducted and flexed against the abdomen. It causes cephalic rotation of the pelvis. Along with this gentle suprapubic pressure is applied by the assistant.

MD Mobarak Hussain  (Maahii)

External Cephalic Version : An overview

Here's a short review on basics of External Cephalic Version.

So this Procedure is basically manipulating the baby externally to come in a favorable cephalic presentation.

Its indications need are limited and mainly include -
Breech Presentation and Transverse Lie.

The most important thing to remember is when not to do an ECV.

You can remember these contraindications as :

ABCDEF

A - Ante partum hemorrhage ( Previa and Abruptio.) It can result in detachment and more Accidental Hemorrhage (Abruption).

B - Bad Obstetric History

C -
Contracted Pelvis - ECV can cause fetal Hypoxia if the pelvis is small already

Congenital uterine Abnormalities - like bicornuate etc as can cause uterine rupture.

D - Dual Pregnancy (Twins/ Multifetal pregnancy).

E - Eclampsia PIH.

F - Fluid - Oligohydramnios

2 other C/I are important to remember -

Previous Cesarean section ( Uterine rupture chances are high).

Rh Incompatibility.

The best time for doing an ECV is around 36-38 weeks. It's easiest to perform the maneuver before 36 weeks but the fetus undergoes a lot of spontaneous movements before 36 weeks and may come back to being Breech.

Beyond 40 weeks best to avoid it as liquor reduces in amount and can cause cord compression amongst other things.

Another pre requisite is having the uterus relaxed. So it may be done in OT set up where anesthesia like Halothane can be used as a uterine relaxant. (Not so sure about the last part as some PG resident in college told us this. :P)

Hope this helps.
Happy Studying !
And as always ,
Stay Awesome !

~ A.P.Burkholderia.

Placenta Previa : Why it occurs.

Here's a short discussion post on Placenta Previa Etiology.

So Placenta Previa is a dangerous condition that presents with bleeding after 28 weeks up to the 1st stage of labour. (So it could so happen that the baby needs to tear it open and come out - as it may cover the Os. Hence Previa , where Previa means 'In front of'. Of course the reality being that the placenta gets compressed and results in fetal Hypoxia along with bleeding ).

The main pathology is that the Placental gets abberantly deposited / implanted in the lower uterine segment in stead of the upper.

This could be due to :
1. Decidual area being defective in the upper segment (Due to maternal age , Multiparity, Curretage or Cesearan section in the past).
2. Large placenta - due to which some part may encroach over the lower segment. (Multiple pregnancy, Smoking etc).

Here's a way to remember the risk / etiological factors for this condition.

Risk Factors for Placenta Previa -

Mnemonic : M4 C3

M - Maternal Age - Decidua becomes weaker with age so the placenta ends up encroaching over the lower segment.
M - Multiparity (Similar reason. Especially in a grand multi para)
M - Multifetal pregnancy (Twins etc. There's less space in the fundal area hence gets lodged in the lower segment)
M - Maternal Serum AFP (Indicates high/persistent Chorionic activity - essentially invades into more and more of the Endometrium.)

C - Curretage - in the past if done , damages the uterine layer making the upper segment defective.
C - Caeserean sections in the past / other operations on the Endometrium/myometrium - Makes the uterus defective.
C - Cigarette smoking - causes Hypoxia to the baby leading to Placental Hypertrophy - larger placenta occupies larger area and may encroach downwards.

Hope this helped !
Stay Awesome and
Happy Studying !
~ A.P.Burkholderia

Drugs used to lower BP acutely in severe preeclampsia mnemonic

Drugs used to lower blood pressure acutely in severe preeclampsia (Maternal hypertensive crisis) mnemonic

"Lower Hypertension Now"

Labetalol iv preferred (Avoid in bradycardia)

Hydralazine iv

Nifedipine oral

That's all!
-IkaN

External cephalic version mnemonic

When should ECV be performed?

Breast feeding and maternal cancer

Breast feeding decreases the risk of all of the following cancers in the mother EXCEPT:

Breast cancer
Ovarian cancer
Endometrial cancer

Episiotomy indications : Mnemonic

Hi everyone.
Posted in Ob-Gyn now. Let's just say it's not a lot of fun looking at diseased hoo-hoo's.
Just kidding.

Here's a Mnemonic for the absolute indications of Episiotomy.

Remember : PPPP

1. Perineum is rigid
2. Perineum has been operated on. (For Prolapse, stress urinary incontinence , etc)
3. Procedures are to be used. (Like Ventouse or Forceps)
4. Position / Presentation are abnormal. (Like Breech , face to pubis, shoulder dystocia , macrosomia)

The other indications which are non-absolute include :
- Maternal exhaustion
- Preterm/ post mature baby
- Trial of labour.

So I hope this didn't tear you up. (Pun intended).
Happy studying !
Stay awesome.
~ A.P.Burkholderia

Maternal factors for IUGR mnemonic

Hello

The maternal factors that increase the risk of Intrauterine Growth Restriction ( IUGR ) in unborn babies ( small - for - dates ) include : MATERNAL RISK

M - Malnutrition / Multiparity
A - Anaemia ( severe )
T - Toxaemias of pregnancy
E - Excess physical activity
R - Raised blood pressure
N - Narrow birth spacing
A - Alcohol intake ( excess ) / Age ( young )
L - Low socio - economic scale

R - Recreational drug use
I - Infections
S - Smoking / Short stature
K


Thats all
- Jaskunwar Singh

Types of abortion: Explanation and mnemonic

Hello!
This video is on the types of abortion.

Infants of Diabetic Mothers (IDM) : A clinical overview

Hello

With the prevalence of insulin - dependent diabetes mellitus and maternal hyperglycemia, serious consequences to the ingrowing foetus may occur during its organogenesis. Lets have a quick review of the clinical problems in the infants of diabetic mothers ( IDM ) with some lame mnemonics :p -

GENERAL BUILT :
- Macrosomia ( birth weight >4,000 gm ) resulting in difficult labor and complications such as traumatic asphyxia, shoulder dystocia, BP injury, etc.
- Large for gestational age

CONGENITAL ANOMALIES :-

1. CARDIOVASCULAR - mnemonic : CASTeD
- Cyanotic heart disease
- Asymmetric septal hypertrophy ( resulating in small LV )
- Septal defects ( VSD, ASD )
- Transposition of blood vessels
- Decreased cardiac output ( due to perinatal asphyxia and metabolic acidosis )

2. SKELETAL AND CNS -
- Caudal regression syndrome
- Mental retardation

3. NEURAL TUBE DEFECTS - mnemonic : HAM

- Holoprosencephaly

- Anencephaly

- Meningomyelocoele

4. RENAL and GENITOURINARY - mnemonic : HURT

- Hydronephrosis

- Urethral dysplasia

- Renal agenesis

- Thrombosis of renal vein

( patient presents with flank mass, intermittent hematuria, and thrombocytopenia )

5. GASTROINTESTINAL - mnemonic : GAS

- Gastrointestinal obstruction ( due to duodenal atresia )

- Anorectal malformations

- Small left colon syndrome

6. RESPIRATORY -
- Hyaline membrane disease ( Infantile RDS )
- Persistent Pulmonary Hypertension

7. METABOLIC changes -

- Hyperbilirubinemia ( due to polycythemia )

- Hypoglycemia occurs 30 - 90 mins post delivery which may take several days to resolve. Rebound hypoglycemia may occur in response to rapid, large boluses of glucose ( 10-15 mg/kg/min ).

- Hypocalcemia ( levels <7 mg/dL ) occurs within hours to days after birth due to a delay in PTH synthesis after birth, often accompanied with Hypomagnesemia.


Thats all
Hope this helps :)

- Jaskunwar Singh

Mnemonico diagnostico : Risk approach to Antenatal cases

Hello

'High - risk' antenatal cases contribute to 70 - 80% of perinatal morbidity and mortality rates. The screening and diagnostic tests to evaluate and identify such cases is a must so as to provide special care to the mother - child duo. Risk approach for antenatal cases according to WHO includes : ( mnemonic - RISK APPROACH )