HTN in Pregnancy
Briefly define each of the following: gHTN/PIH, Pre-eclampsia, Eclampsia, HELLP syndrome
gHTN/PIH - de novo HTN in pregnancy (>140 SBP OR >90 DBP) diagnosed after 20 weeks gestation and without proteinuria
Pre-eclampsia - de novo HTN in pregnancy diagnosed after 20 weeks gestation WITH proteinuria
Eclampsia - Pre-eclampsia + seizures
HELLP - Hemolysis, Elevated Liver enzymes, Low Platelets, usually with HTN, though may be normotensive
What does the acronym PALM-COEIN stand for?
PALM = Structural causes. These are polyps, adenomyosis, leiomyomas, malignancy
COEIN = Non-structural causes. Coagulopathy, Ovulatory, Endometrial (think infection), Iatrogenic, NOS
Low lying placenta is defined as the trailing edge of the placenta being within what distance of the internal cervical os?
<2 cm
What services do we provide at the cervical cancer clinic at the White Haus?
Visual inspection with acetic acid. HPV testing for high risk strains when available. Thermo-ablation for treatment of low grade lesions.
What is the minimum appropriate time interval to check for fetal growth in the third trimester?
2 weeks
What are the respective target values for treatment of severe range HTN and mild-moderate range HTN?
Initial management of severe HTN <160 SBP and <110 DBP
Titrate management of severe HTN to <150 SBP and <100 DBP
Mild to Moderate HTN <140 SBP and <90 DBP
In what age group must abnormal bleeding be further investigated for cancer prior to attempting any medical treatment?
Postmenopausal women. (Menopause defined as cessation of menses for 12 consecutive months).
How might a full bladder and uterine contractions each respectively affect the appearance of placental location?
They can both cause the placenta to inaccurately appear closer to the os
What percentage of cervical cancers can be attributed to the HPV virus?
99.7%
What is the minimum gestational age at which an operative delivery with vacuum is deemed safe?
34 weeks
What is our Magnesium Sulfate protocol?
Loading dose of 10g IMI (5g each thigh).
Maintenance dose of 5g IMI in alternating thighs q6 hrs. Continue x24 hrs PN or for 24hrs following last seizure (whichever is later)
Name two non-hormonal medications that can be used in the treatment of heavy menstrual bleeding.
Tranexamic acid and NSAIDs
What common class of medicines given in obstetrics is contraindicated in the setting of placental abruption?
Tocolytics
Describe the continuum of cervical dysplasia
HPV infection --> Low grade dysplasia/LSIL/CIN1-2 --> High grade dysplasia/HSIL/CIN3 --> Carcinoma in situ --> overt cancer
Your initial ultrasound demonstrates a gestational sac without yolk sac - what is an appropriate length of time after which you can safely diagnose a missed AB due to the absence of an embryo with a heartbeat?
2 weeks
What is the optimal delivery timing for the following diagnoses: gestational HTN/PIH, pre-eclampsia without end organ damage, severe pre-eclampsia/with end organ damage, and HELLP?
gHTN - early term/37 weeks
Pre-eclampsia - early term/37 weeks with close surveillance for progression
PreE with severe disease - immediately (may be able to delay for steroid administration as needed)
HELLP - >35 wks deliver, <35 wks can consider delay for steroids
Which PALM-COEIN category is the most common non-structural cause of abnormal bleeding in reproductive-aged women?
Ovulatory dysfunction (AUB-O)
What is the percent sensitivity of ultrasound in the diagnosis of placental abruption?
25%
What stage of cervical cancer is amenable to treatment with surgical excision?
<Stage II. Rarely some stage II cases. Essentially, this means disease is confined to cervix.
Name 4 ultrasound characteristics of ovarian masses that are concerning for malignancy
Presence of ascites
Size >10 cm
Irregular solid components
Papillations
Rich vascularity
What criteria qualify a patient with pre-eclampsia for a diagnosis of severe disease/end organ damage?
Severe HTN, Renal dysfunction (evidenced by serum Cr >1.0 OR oliguria <500mL/24h), Hepatic involvement (elevated transaminases with RUQ/epigastric pain), Neurologic complications (AMS, persistent severe HA, visual symptoms/scotoma), Hematologic complications (platelets <100,000), Pulmonary edema
Describe adenomyosis (can contrast to endometriosis) and its typical presentation.
Adenomyosis is a special form of endometriosis where there is invasion of the endometrium into the myometrial layer of the uterus. Adenomyosis classically prevents as heavy, painful menses. PE uterus usually slightly enlarged and boggy, US junctional zone between endometrium and myometrium can appear "fuzzy" and myometrium can look heterogenous, asymmetric, & coarse
What is a concealed placental abruption and how might it present?
This is a retroplacental hemorrhage occurring between the placenta and myometrium. There is typically minimal to no vaginal bleeding, significant abdominal pain/uterine tenderness, uterine irritability and/or tetanic contractions, and possibly maternal shock.
What treatment options exist for cervical dysplasia/pre-cancer and cancer?
Observation, Thermo-ablation, LEEP/LLETZ, Hysterectomy, Radiation/Concurrent chemo-radiation
What is the WHO recommended treatment for pelvic inflammatory disease?
1. Ceftriaxone 250mg IM x1 PLUS
2. Azithromycin 1g PO x1 PLUS
3. Doxycycline 100mg PO BD x14d PLUS
4. Metronidazole 400 or 500mg PO BD x14d