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OB13Obstetrics Toronto Notes 2023

Risk Factors

• lose parity, prolonged ROM,long labour, multiple vaginal exams during labour, and internal

monitoring

• bacterial vaginosis and other vaginal infections

Clinical Features of Chorioamnionitis

• Temperature

• Tachycardia (maternal or fetal)

• Tenderness (uterine)

. Foul discharge

Clinical Features

• maternal fever >38°C, maternal or fetal tachycardia, uterine tenderness, and foul and purulent

cervical discharge

Investigations

• CBC:leukocytosis, elevated serum lactate

• amniotic fluid:Gram stain,glucose,or culture results consistent with infection

Treatment

• IV antibiotics

ampicillin 2 g IV q6 h + gentamicin 2 mg/kg load, then 1.5 mg/kg IV q8 h

• anaerobic coverage (i.e.clindamycin 900 mg IV q8 h)

• if at risk for endometritis, continue treatment postpartum especially if CD

• antipyretics

• proper labour progression ( not an indication for immediate delivery or CD, especially if deliver}- is

imminent and can be done safely)

Complications

• bacteremia of mother or fetus,wound infection if CD, pelvic abscess, neonatal meningitis,maternal or

neonatal sepsis, and neonatal death

• long-term infant complications:cerebral palsy and bronchopulmonary dysplasia

Meconium

Epidemiology

• present early in labour in 10% of pregnancies, more common in postterm pregnancies

• in general, meconium may be present in up to 25% of all labours; usually NOT associated with poor

outcome

• concern if fluid changes from clear to meconium-stained

• always abnormal ifseen in preterm fetus

Particulate (thickened) meconium is

associated with lower APGARs.an

increased risk of meconium aspiration,

and perinatal death,fferticulate

meconium generally has a darker green

or black colour,whereasthin meconium

Etiology is usually yellow to Eght green

• likely cord compression r uterine hypertonia

• may indicate undiagnosed breech

• increasing meconium during labour may be a sign of fetal distress

Features

• may be watery or thicker (particulate)

• light yellow-green or dark green-black in colour

Treatment

• call respiratory therapy, neonatology,or paediatrics to delivery room

• closely monitor l-

'

HR for signs of tetal distress

Operative Obstetrics

Prerequisitesfor Operative Vaginal

Delivery

Operative Vaginal Delivery ABCDEFGHUK

Anes thesia (adequate)

Bladder empty

Cervix fully dilated and effaced with Definition

• forceps or vacuum extraction ROM

Determine position of fetal head

Equipment ready (including facilities

for emergent CD)

Fontanelle (posterior fontanelle

Indications

• fetal:

• atypical or abnormal f HR tracing, evidence of fetal compromise

• consider if second stage is prolonged, as this may be due to poor contractions or failure of fetal

head to rotate

gway mid between thighs)

Gentle

^

traction ri

Handle elevated

Incision (episiotomy)

Once jaw visible remove forceps

Knowledgeable operator

lJ

• maternal:

need to avoid voluntary expulsive effort (e.g. cardiac/cerebrovascular disease)

exhaustion, lack of cooperation,and excessive analgesia may impair pushing effort

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OBI1Obstetrics Toronto Notes 2023

Contraindications

• cervix not fully dilated

• membranesintact

• unknown fetal head position

• unengaged head

• fetal bone demineralization disorder (e.g. osteogenesis imperfecta)

• fetal bleeding disorder (e.g. hemophilia or VWD)

Forceps

Outlet Forceps

• head visible between labia in between contractions

• sagittal suture in or close to AP diameter

• rotation cannot exceed 45°

Low Forceps

• presenting part atstation +2 or greater

• subdivided based on whether rotation less than or greater than 45°

Mid Forceps

• presenting part below spines but above station +2

Types of Forceps

Simpson or Tucker-McLane forceps for OA presentations

• Kielland (rotational) forceps when rotation of head or correction of asynclitism is required

• Piper forceps for after-coming head in breech delivery

• Wrigley’sfor preterm babies

A Simpson forceps

B.Tucker-McLane forceps

C.Kielland forceps

0.Piper forceps

Figure 9. Types of forceps

Vacuum Extraction

• traction instrument used as alternative to forceps delivery’;aids maternal pushing

contraindications: <34 wk GA (<2500 g), fetal head deflexed,fetus requires rotation,fetal condition

(e.g. bleeding disorder)

Limits for Trial of Vacuum

• After 3 puls over 3 contractions with

no progress

. After 3 pop-offs with no obvious

cause

• 20 mil and delivery is not imminent

Table 21. Advantages and Disadvantages of Forceps vs. Vacuum Extraction

Forceps Vacuum Extraction

Higher overall success rate for vaginal delivery Easier to apply

Decreased incidence of fetalmorbidity

Advantages

Less anesthesia required

Less maternal soft tissue injury compared to

forceps tiskFactors fortke Devetopweit of Obstetric

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Disadvantages Greater incidence of maternal injury Suitable only for vertexpresentations

Contraindicated in preterm delivery

Maternal:anesthesia risk.cervical/vaginaL1

Increased incidence of cephalohematoma.

perineal lacerations Including OASIS,injury to retinal hemorrhages,and jaundree compared

bladder,uterus,or bone,pelvic nerve damage, to forceps

PPH,and infections

Fetal:fractures,facial nerve palsy,trauma

to face/scalp,intracerebral hemorrhage,

cephalohematoma,and cord compression Increased maternal risk of perineal

lacerationsOASIS.PPH.andinfection

Complications

Subgaleal hemorrhage

Subaponeurotic hemorrhage

Soft tissue trauma

Perineal Lacerations

• 1st degree: involvesskin and vaginal mucosa but not underlying fascia and muscle

• 2nd degree:involves fascia and muscles of the perineal body but not the analsphincter

• 3rd degree:involves the analsphincter (3A:<50% of external analsphincter;3B:>50% of external anal

sphincter;3C:external and internal analsphincters)

• 4th degree:extends through the analsphincter complex (external and internal) and into the rectal

mucosa

• for 3rd and 4th-degree tears:

a single prophylactic dose of IV antibiotics (2nd generation cephalosporin, e.g.cefoxitin or

cefotetan) should be administered to reduce perineal wound complications

laxativesshould also be prescribed and constipation should be avoided

recommend postpartum pelvic physiotherapy and endoanal U/S to assess integrity of anal

sphincters 3-4 mo post repair

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OB45Obstetrics Toronto Notes 2023

Episiotomy

Common OR Questions Definition

• incision in the perineal body at the time of delivery

• essentially a controlled 2nd degree laceration

• midline: incision through central tendinous portion of perineal body and insertions of superficial

transverse perineal and bulbocavernosus muscles

heals better, but increases risk of extension into a 3rdMth degree tear

• mediolateral: incision through bulbocavernosus,superficial transverse perineal muscle, and levator

ani, 60* angle from midline

• reduces risk of extensive tear, but more painful

7Layers to Dissect

Skin,fatty layetfascia,muscle

separation (rectus abdominis),

peritoneum, bladder flap, uterus

Layers of the Rectus Sheath

Above the arcuate line:anterior rectus

sheath (aponeurosis of external oblique,

anterior internal oblique), rectus

abdominis, posterior rectussheath

(aponeurosis of posterior internal

internal oblique, transversus abdominis)

Below the arcuate line: aponeurosis

of external oblique, internal oblique,

transversus abdominis (all anterior)

Indications

• to relieve obstruction of the unyielding perineum

• to expedite delivery (e.g. abnormal l-

'

HK pattern)

• instrumental delivery

• controversial between practitioners as to whether it is preferable to make a cut or let the perineum tear

as needed

• current evidence suggestsletting perineum tear and then repair as needed (restricted use)

Name of the Obliterated Umbilical

Ligament

Urachus

Complications

• infection, hematoma, extension into anal musculature or rectal mucosa,fistula formation, and

incontinence

Most CDs are performed with regional

analgesia Caesarean Delivery

Epidemiology

• overall 28% rate in Canada (range 185-35.3% by province/territory) 75 '

4 r

-

Indications

• maternal: obstruction of descent (e.g.maternal fibroids), active herpetic lesion on vulva, invasive

cervical cancer, previous uterine surgery (past CD is most common),and underlying maternal illness

(eclampsia, HELLP syndrome,heart disease)

• maternal-fetal:failure to progress, placental abruption or previa,and vasa previa

• fetal: abnormal fetal heart tracing,malpresentation,cord prolapse, certain congenital anomalies, and

multiple gestation

. 8

I

s

/

-

V

Ikin l -Fatty Layer

-Rectus

Abdominus

Types of Caesarean Incisions

• skin /

•

Pfannenstiel

decreased exposure

improved strength and cosmesis

reduced pain

• vertical midline

rapid peritoneal entry and increased exposure (e.g.obstruction due to large fibroids)

increased dehiscence

fascia

’

eritoneum ^

rr

ladder Rap

Figure10. Layersto dissect

• uterine

low transverse:in non-contractile lowersegment

decreased chance for rupture in subsequent pregnancies

low vertical

used for very preterm infants or poorly developed maternal lower uterine segment

classical (rare):in thick,contractile segment

used for transverse lie with fetal back down, preterm breech, fetal anomaly, >2 fetuses, lower

segment adhesions,obstructing fibroid, and inaccessible lower uterine segment (e.g. morbid

obesity)

Risks/Complications

• anesthetic complications (e.g.aspiration)

• hemorrhage (average blood loss -1000 mL)

• infection (UT1, wound, and endometritis)

single dose prophylactic antibiotic should be used (e.g. cefazolin 1-2 g IV)

• injury to surrounding structures(bowel,bladder, ureter, and uterus)

• thromboembolism (DVT, PE)

• increased recovery time/hospital stay

• maternal mortality (<0.I%)

• subsequent placenta accreta

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OB16Obstetrics Toronto Notes 2023

Trial of Labour after Caesarean (TOLAC)

TOLAC

• Rate of successful TOLAC ranges

from 60-82%

• No significant difference in maternal

deaths or hysterectomies between

TOLAC or CD

• Uterine rupture more common in

TOLAC group

• Evidence regarding fetal outcome

is lacking

•should be recommended if no contraindications after previouslow transverse incision

•success rate varies with indication for previousCD (generally 60-80%)

•risk of uterine rupture (<1% with low transverse incision), increased by interval <18 mo and oxytocin

administration

Contraindications

•previous classical, inverted T, or unknown uterine incision, or complete transection of uterus(6% risk

of rupture)

•any contraindication to vaginal birth,such as placenta previa

•inadequate facilities or personnel for emergency CD 'Safely ol vaginal bulh after Caeureaesccfeac A

sy&lemaiic renew.0tfttetGyn«ol 2OOU03 420-429

Postpartum Period Complications

• puerperium:6 wk period of adjustment after pregnancy when pregnancy-induced anatomic and

physiologic changes are reversed

Postpartum Hemorrhage

Definition

• loss of >1000 mL of blood after CD, >500 mL of blood after vaginal delivery,or bleeding associated

with signs/symptoms of hypovolemia within 24 h of birthing process regardless of mode of delivery

• primary - within first 24 h postpartum

• secondary - after 24 h but within first 12 wk

Uterine atony isthe most common cause

ofPPH

Epidemiology

• incidence 5-15%

(§)

Etiology (4 Ts)

1.Tone (uterine atony)

most common cause of PPH (70-80%) DDx of Early PPH-4 Ts

To ne (atony)

Tissue (retained placenta,dots)

Trauma (laceration,inversion)

Thrombin (coagulopathy)

avoid with active management of 3rd stage oflabour with 1) oxytocin administration;2) uterine

massage;and 3) umbilical cord traction for delivery of the placenta

due to:

overdistended uterus (polyhydramnios,multiple gestations, and macrosomia)

uterine muscle exhaustion (prolonged or rapid labour,grand multiparity,oxytocin use,and

general anesthetic)

uterine distortion (fibroids)

intra-amniotic infection (fever or prolonged ROM)

bladder distension (preventing uterine contraction)

DDx of Late PPH

Retained products

t endometritis

Sub-involution of uterus

2.Tissue

• retained placental products (membranes, cotyledon,orsuccenturiate lobe)

• retained blood clots in an atonic uterus

GIN

• abnormal placentation (e.g.placenta accreta)

3.Trauma

laceration (vagina, cervix,or uterus),episiotomv, hematoma (vaginal,vulvar,or retroperitoneal),

uterine rupture, and uterine inversion

4.Thrombin

coagulopathy (pre-existing or acquired)

• most identified prior to delivery (low platelets increases risk)

• includes hemophilia, DIG,IIP.TIP,and VWD

• therapeutic anti-coagulation

Investigations

• assess degree of blood loss and shock by clinical exam

• explore uterus and lower genital tract for evidence of atony, retained tissue, or trauma

• may be helpful to observe red-top tube of blood - no clot in 7-10 min indicates coagulation problem

Management

• ABCs,call for help

• 2 large bore IVs,run crystalloids wide open

• CBC,coagulation profile,fibrinogen, cross and type packed RBCs

• treat underlying cause

• Foley catheter to empty bladder and monitor urine output

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OB47Obstetrics Toronto Notes 2023

Medical Therapy for Atony

• oxytocin 10 III IM is preferred in low-risk vaginal deliveries, oxytocin IV infusion (20-401U in 1000

mL crystalloid at 150 mL/h) is an acceptable alternative;oxytocin 5-101U IV bolus (20-40 IU in 250

mL crystalloid) can be used after vaginal birth, but not with elective CD

• carbetocin, a long-acting oxytocin, 100 pg IV bolus over 1 min for elective CD or 100 pg IM for vaginal

deliveries with 1 risk factor for PPH (instead of a continuous oxytocin infusion)

• methylergonovine maleate (Ergotamine*) 0.25 mg IM/slow IV q2 h up to 1.25 mg; can be given as IV

bolus of 0.125 mg (contraindicated in HTN)

• carboprost (Hemabate*), a synthetic PGFia analog, 250 pg IM /1MM ql 5 min to max 2 mg (major

prostaglandin side effects and contraindicated in cardiovascular, pulmonary (asthma), renal, and

hepatic dysfunction)

• misoprostol (Cytotec*) 600-800 pg PO/SL (faster) or PR/PV (side effect: pyrexia if >600 pg)

• tranexamic acid (Cyklokapron*), an antifibrinolytic, 1 g IV

Local Control for Atony

• bimanual massage: elevate the uterus and massage through patient’s abdomen

• uterine packing (mesh with antibiotic treatment)

• Bakri Balloon for tamponade:may slow hemorrhage enough to allow time for correction of

coagulopathy or for preparation of an OR

• manual removal if retained placenta (can also be used to treat PPH due to other causes)

Surgical Therapy (Intractable PPH) for Atony

• D&C (beware of vigorous scraping, which can lead to Asherman'

s syndrome) (can also be used to treat

PPH due to other causes)

• embolization of uterine artery or internal iliac artery by interventional radiologist

• laparotomy with bilateral ligation of uterine artery (may be effective), or internal iliac artery ±

compression sutures(B-Lynch or Cho sutures) (can also be used to treat PPH due to trauma and early

thrombus)

• hysterectomy last option, with angiographic embolization if post-hysterectomy bleeding

Retained Placenta

Definition

• placenta undelivered after 30 min postpartum

Etiology

• placenta separated but not delivered

• abnormal placental implantation (placenta accreta, placenta increta, and placenta percreta)

Risk Factors

• placenta previa, prior CD,post-pregnancy curettage,prior manual placental removal, and uterine

infection

Clinical Features

• risk of PPH and infection

Investigations

• explore uterus

• assess degree of blood loss

Management

• 2 large bore lVs, type and screen

• Brandt maneuver (firm traction on umbilical cord with one hand applying suprapubic pressure

ccphalad to avoid uterine inversion by holding uterus in place)

• oxytocin 10 IU in 20 mL normal saline into umbilical vein

• manual removal if above fails

• D&C if required ( U/S guidance if available)

• cefazolin 2 g IV if manual removal or D&C

Uterine Inversion

Definition

• inversion of the uterusthrough cervix ± vaginal introitus rn

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Etiology/Epidemiology

• often iatrogenic (excess cord traction with fundal placenta)

• excessive use of uterine tocolytics

• more common in grand multiparous women (lax uterine ligaments)

• 1 in 1500 to 1 in 2000 deliveries

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OB18 Obstetrics Toronto Notes 2023

Clinical Features

• can cause profound vasovagal response with bradycardia, vasodilation, and hypovolemic shock

• shock may be disproportionate to maternal blood loss

Management

• urgent management essential,call anesthesia

• ABCs:initiate IV crystalloids

• can use tocolytic drug (see Preterm Labour, OBIT ) or nitroglycerin IV to relax uterus and aid

replacement

• replace uterus without removing placenta

• remove placenta manually and withdraw slowly

• IV oxytocin infusion (only after uterus replaced)

• re-explore uterus

• may require general anesthetic ± laparotomy

Postpartum Pyrexia

Definition

• fever >38°C on any two of the first 10 d postpartum,except the 1st day

Etiology

• endometritis

• wound infection (check CD and episiotomy sites)

• mastitis/breast engorgement

• UT1

• atelectasis

• pneumonia

• DVT or pelvic thrombophlebitis

(§>

Etiology of Postpartum Pyrexia

B-5W

Breast:engorgement,mastitis

Wind:atelectasis, pneumonia

Water:UTI

Wound: episiotomy.CD site infection

Walking: DVT.thrombophlebitis

Womb:endometritis

Investigations

• detailed history and physical exam,relevant cultures

• for endometritis:blood and genital cultures

• serum lactic acid for early detection ofsepsis

Treatment

• depends on etiology

• infection:empiric antibiotics, adjust when sensitivities available

• endometritis:clindamycin + gentamicin/tobramycin IV

• mastitis:cloxacillin or cephalexin

• wound infection:cephalexin + frequentsitz bathsfor episiotomy site infection

DVT:anticoagulants

• prophylaxis against post-CD endometritis:administer cefazolin 2-4 g IV (based on BM1) 30 min prior

to skin incision

ENDOMETRITIS

• definition:inflammation of the endometrium most commonly due to infection

• clinical features:fever, chills, abdominal pain, uterine tenderness, foul-smelling vaginal discharge, or

lochia

• treatment: depends on infection severity; oral antibioticsif well,IV antibiotics with hospitalization in

moderate to severe cases

Risk Factorsfor Endometritis

CD. intrapartum chorioamniomtis.

prolonged labout prolonged ROM.and

multiple vaginal examinations

VENOUS THROMBOEMBOLISM

. see Venous thromboembolism, OB32

Mastitis

• definition:inflammation of mammary glands

• must rule out inflammatory carcinoma,asindicated

• differentiate from mammary duct ectasia:mammary duct(s) beneath nipple clogged and dilated ±

ductal inflammation ± nipple discharge (thick,grey to green), often postmenopausal women

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OB19 Obstetrics Toronto Notes 2023

Table 22. Lactational vs. Non-Lactational Mastitis

Lactational Non-Lactational

Epidemiology More common than non-lactational

Often 2 3 wk postpartum

S.aureus

Periductal mastitis most common

Mean age 32 yt

May be sterile

May beinfected with S. aureus or other anaerobes

Smoking is risk factor

May be associated with mammary duct ectasia

Subareolar pain

May haiesubareolar mass

Discharge (variable colour)

Nipple inversion

Broad-spectrum antibiotics and ISO

Total duct eversion (definitive)

Etiology

Symptoms Unilateral localited pain

Tenderness

Erythema

Treatment Heat or ice packs

Continued nursinglpumping

Antibiotics (clovacillim'cephalexin) (erythromycin if

penidllin-allergic)

Fluctuant mass

Purulent nipple discharge

Fever,leukocytosis

Discontinue nursing,IVantibiotics (nafcillin/

oxacillin),ISD usually required

If mass does not resolve,fine-needle aspiration to exclude

cancer and U/S to assess presence of abscess

Treatmentindudes antibiotics,aspiration,or ISD (tends

to recur)

May develop mammary dud fistula

Aminority of non-lactational abscesses may occur

peripherally in breast with no associated periductal mastitis

(usuallyS.aureus)

Abscess

Postpartum Mood Alterations

POSTPARTUM BLUES

• 40-80% of new mothers, onset 3-10 d postpartum;extension of the “normal” hormonal changes and

ad justment to a new baby

• self-limited,should resolve by 2 wk

• manifested by mood lability, depressed affect, increased sensitivity to criticism, tearfulness,fatigue,

irritability, poor concentration/despondency, anxiety, and insomnia

POSTPARTUM DEPRESSION

• definition:major depression occurring in a woman within 6 mo of childbirth (see Psychiatry, PS14)

• epidemiology:10-15%, risk of recurrence 50%

• risk factors:

personal or family history of depression (including PPD)

prenatal depression or anxiety

• stressful life situation

• poor support system

• unwanted pregnancy

• colicky or sick infant

• clinical features:suspect if the “blues” last beyond 2 wk,or if the symptoms in the first 2 wk are

severe (e.g. extreme disinterest in the baby,suicidal or homicidal/infanticidal ideation)

• assessment: Edinburgh Postnatal Depression Scale or others

• treatment:antidepressants, psychotherapy,supportive care,and electroconvulsive therapy if

refractory

• prognosis:interferes with bonding and attachment between mother and baby,so it can have longterm effects

POSTPARTUM PSYCHOSIS

• definition: acute psychotic episode triggered by the complex psychosocial stressors and hormonal

changes that occur following childbirth.Symptoms usually present within the first 2 wk but can last

for months

• epidemiology:rare (0.2%), but 50% risk of recurrence in next pregnancy if experienced in

previous pregnancy. Increased risk in individuals with bipolar disorder,schizoaffective disorder,

schizophrenia,or other psychotic illness, or personal or family history of postpartum psychosis

• treatment: psychiatric emergency as risk of infanticide. Typically requires hospitalization, mood

stabilizer, and antipsychotics

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OB50 Obstetrics Toronto Xotes 2023

Postpartum Care

The acronym “

BUBBLES" for what to

ask about when rounding on postpartum

care.Modify this for CO or vaginal

delivery

Postpartum Office Visit at 6 Weeks

Care of Mother (The 10 Bs)

• Be careful: do not use douches or tampons for 4-6 wk post-delivery

• Be fit: encourage gradual increases in walking, Kegel exercises

• Birth control:assess for use of contraceptives

• Breastfeeding is not as effective as other methods of birth control (see Gynaecology, GY15, for more

detail about different contraceptive options postpartum)

lactational amenorrhea approved by WHO for up to 6 mo if meets criteria: l) amenorrhea; 2)

fully or nearly fully breastfeeding (no interval of >4-6 h between breastfeeds); and 3) <6 mo

postpartum

• Bladder: assess for urinary incontinence, maintain high fluid intake

• Blood pressure: especially if gestational H'

l N

• Blood tests:CBC (for anemia if had PPH, TSH ifsubcli nical hypothyroidism in pregnancy, 75g OGTT

if GUM)

• Blues: (see Postpartum MootI Alterations, OH 49)

• Bowel:fluids and high-fibre foods, bulk laxatives; for hemorrhoids/perineal tenderness: pain nteds,

doughnut cushion, sitz baths, and ice compresses

• Breast and pelvic exam: watch for Staphylococcal or Streptococcal mastitis/abscess,t Pap smear at 6

wk if due for screening

8aby care and breastfeeding- Latch?

Amount?

Uterus - Firm or boggy?

Bladder function - Voiding well?

Dysuria?

Bowel function -Passing gas or stool?

Constipated?

Lochia or discharge - Any blood?

Episiotomy/laceration/incision - Pain

controlled?

Symptoms of VTE - Dyspnea? Calf

pain?

Physiological Changes Postpartum

• uterus weight rapidly diminishes through catabolism, cervix loses its elasticity and regains firmness

• should involute -I cm below umbilicus per day in first 4 -5 d, reaches non-pregnant state in 4-6

wk postpartum

• ovulation resumes in -45 d after giving birth, non-lactating women usually ovulate sooner than

lactating women

• lochia: normal vagina) discharge postpartum, uterine decidual tissue sloughing

• decreases and changes in colour from red (lochia rubra; presence of erythrocytes, 3-4 d ) > pale

(lochia serosa) > white/yellow (lochia alba; residual leukorrhea) over 3-6 wk

• foul-smelling lochia suggests endometritis

Breastfeeding Problems

• inadequate milk: consider domperidone

• breast engorgement: cool compress, manual expression/pumping

• nipple pain: clean milk off nipple after feeds, moisturizer, topical steroid if needed

• mastitis:treat promptly (see Postpartum Pyrexia, OHdS )

• inverted nipples: makes feeding difficult

• maternal medications: may require paediatric consultation (see Breastfeeding and Drugs, O H M )

Bladder Dysfunction

• pelvic floor prolapse can occur after vaginal delivery

• stress or urge urinary incontinence common

• increased risk with instrumental delivery or prolonged second stage

• conservative management for stress and urge incontinence: pelvic floor retraining with Kegel

exercises/pelvic physiotherapy, vaginal cones or pessaries, and lifestyle modifications (e.g. limit fluid,

caffeine intake, local vaginal estrogen in breastfeeding women to strengthen vaginal mucosa)

Puerperal Pain

•

“after pains” common in first 3 d due to uterine contractions; encourage simple analgesia

• ice packs and sitz baths can be used on perineum if painful

• encourage regular analgesia and stool softener

Breastfeeding and Drugs

Table 23. Drug Safety During Breastfeeding

Safe During Breastfeeding Contraindicated When Breastfeeding

Chloramphenicol (bone marrow suppression)

Cyclophosphamide (immune system suppression)

depressants (e.g.sertraline,fluoxetine,tricyclic antidepressants) Sulphonamides (in G 6PD deficiency, can lead to hemolysis)

Antiepileptics(e.g. phenytoin. carbamazepine.valproic acid) Nitrofurantoin (in G 6PD deficiency,can lead to hemolysis)

Antihistamines Tetracycline

Antimicrobials (e.g. penicillins,aminoglycosides, cephalosporins) Lithium

P-adrenergics(e.g. propanolol,labetalol)

Insulin

Steroids

OCP (low dose) - although estrogen- containing OCPs may decrease breast Psychotropic drugs (relative contraindication)

milk production

Analgesics (e.g. acetaminophen.NSAIDs)

Anticoagulants(e.g. heparin) r »

'

r \ L J

Phenindione

Bromocriptine

Antineoplastics and immunosuppressants

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Common Medications

Table 24. Common Medications

Drug Name (Brand Name) Dosing Schedule IndicationsFComments

betamethasone valerate (Celestone'

)

carboprost (Hemabate )

12 mgIM q24 h x 2 doses

0.25 mg IMi'IMM q15 min

Mai 2 mg

2 g IV then1g q3 h

900 mg IV q8 h

6 mg IM q12 h x 4 doses

10 mg PV (remove after 12 h)

Mai 3 doses

2 tablets qhs 1tablet qam *

1tablet qpm

Max 3 tabletsi'd

250 mgP0 q6 hx10 d

Enhancement ol fetal pulmonary maturity for Pit

Treatment of uterine atony

cefaiolin

clindamycin

dexamethasone

dinoprostone (Cervidil :PGE2 impregnated

thread)

doxylamine succinate (Diclectin:

)

GBS prophylaxis (penicillin allergic and not atrisk for anaphylaxis)

Used in endometritis

Enhancement of fetal pulmonary maturity for PTL

Induction of labour

Advantage:can remove if tachysystole

Each tablet containslO mg doxylamine succinate with vitamin Bs

Used first-line for NlV inpregnancy,including hyperemesis gravidarum

To prolong pregnancy and decrease maternal and neonatalmorbidity for

patients who are not in labour in PPROM

Prevention of ONTO

erythromycin

folic acid 0.4-1mg PO once daily *

1-3 mo preconception and T1

4 mg PO once daily with past Hx of HTD.'

high risk for NTD

0.25 mg IM.

'

slow IV q2 h up to1.25 mg or IV bolus 0.125 mg

600-1000 pg PR 11dose

400 pg P0/Slx1dose

or 800 pg PV 11dose 3-7 d after methotrexate

0.5-2.0 mU/min IV or 10 IU/L normal saline increase by1-2 mUfmin q20-60 Induction/augmentation of labour

Prevention of uterine atony

10 IU IM at delivery of anterior shoulder (or after delivery of placenta) Treatment of uterine atony

20 IU7Lnormal saline or Ringer’s Lactate IV continuous infusion

5 million IU IV.then 2.5 million IU IV q4h until delivery

0.5 mg PV q6-12h;Max 3 doses

300 pglMxl dose

methylergonovine maleate (Ergotamine - )

misoprostol (Cytotecr )

Treatment of uterine atony

For treatment of PPH

For medical abortion/retained products of conception

oxytocin (Pitocin-)

min

penicillin G

PGE2gel (Prostin = gel)

Rh IgG [RhoGAM )

GBS prophylaxis

Induction of labour

Given toRh-negative women

Routinely at 28 wkGA

Within 72 h of birth of Rh*

fetus

Positive Kleihauer-Betke test

With any invasive procedure in pregnancy

Ectopic pregnancy

Antepartum hemorrhage and first trimester bleeding

Miscarriage or therapeutic abortion (dose:50 pg IM only)

Landmark Obstetrics Trials

Trial Name Reference Clinical Trial Details

PRETERM LABOUR

NEJM 2003; Title:Prevention of Recurrent Preterm Delivery by 17 a-Hydroxyprogesterone Caproate

348:2379 - 2385 Purpose:Confirm the results of several small trials that have suggested that the use of a-hydroxyprogesterone caproate (17P) may reduce therisk of recurrent

preterm delivery.

Methods:Double-blind placebo-controlled trial involved pregnant women with a history of spontaneous preterm delivery. Women received weekly injections

of either 250 mg17P or an inert placebo until delivery or 36 wk 6A.

Results: Treatment with 17P significantly reduced the risk of delivery at <37 wk (36.3% vs.54.9%),<35 wk (20.6% vs.30.7%),and <32 wk (11.4% vs.19.6%).

Infants of v/omen treated with17P had lower rates of enterocolitis,hemorrhage,and need for supplemental oxygen.

Conclusion:Weekly injections of 17P resulted in substantial reductions in the rate of recurrent preterm delivery among women and reduced the likelihood of

several complications in the infants.

Meis Trial

MULTI-FETAL GESTATION

Twin Birth Study NEJM 2013;

369:1295-1305

Title: A Randomized Trial of Planned Cesarian or Vaginal Delivery for Twin Pregnancy

Purpose:Twin births are associated with a higher risk of adverse perinatal outcomes.It is unclear whether CD results in lower risk of negative outcomes than

vaginal delivery in twin pregnancies.

Methods:Women between 32-38+6 GA with a twin pregnancy and with the first twin in the cephalic position were randomly assigned to planned CD or

planned vaginal delivery.

Results: There was no significant difference in the outcomes between the planned CD and the planned vaginal delivery group (2.2% and1.9%,respectively;

odds ratio withplanned CD 1.16;95% confidence interval. 0.77 to1.74; p-0.49).

Conclusion:There was no benefit from planned CD compared with planned vaginal delivery of twins between 32 and 38 wk GA if the first twin was in the

cephalic position.

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Ophthalmology

Michael Balas, Josh Herman, and Michelle Lim, chapter editors

Vrati M. Mehra and Chunyi Christie Tan, associate editors

Arjan S. Dhoot,EBM editor

Dr. Asim AH, Dr. VVat-Ching Lam, and Dr. Jonathan Micieli,staff editors

Acronyms

Basic Anatomy Review

Differential Diagnoses of Common Presentations,

Loss of Vision

Red Eye

Ocular Pain

Floaters

Flashes of Light (Photopsia)

Photophobia (Severe Light Sensitivity)

Diplopia (Double Vision)

Ocular Problems in the Contact Lens Wearer

Ocular Emergencies.

The Ocular Examination

Optics

The Orbit

Globe Displacement

Preseptal Cellulitis

Orbital Cellulitis

Lacrimal Apparatus.

Dry Eye Syndrome (Keratoconjunctivitis Sicca)

Epiphora (Excessive Tearing)

Dacryocystitis

Dacryoadenitis

Lids and Lashes

Lid Swelling

Ptosis

Trichiasis

Entropion

Ectropion

Flordeolum (Stye)

Chalazion

Blepharitis

Xanthelasma

OP2 Vitreous

Posterior Vitreous Detachment

Vitreous Hemorrhage

Endophthalmitis and Vitritis

Retina

Central/Branch Retinal Artery Occlusion

Central/Branch Retinal Vein Occlusion

Retinal Detachment

Retinitis Pigmentosa

Age-Related Macular Degeneration

Glaucoma

Primary Open-Angle Glaucoma

Normal Tension Glaucoma

Secondary Open-Angle Glaucoma

Primary Angle-Closure Glaucoma

Secondary Angle-Closure Glaucoma

Pupils

Pupillary Light Reflex

Pupil Abnormalities

Dilated Pupil (Mydriasis)

Constricted Pupil (Miosis)

Relative Afferent Pupillary Defect

Malignancies

Lid Carcinoma

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Metastases

Ocular Manifestations of Systemic Disease

HIV/AIDS

Other Systemic Infections

Diabetes Mellitus

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Multiple Sclerosis

Transient Ischemic Attack/Amaurosis Fugax

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Connective Tissue Disorders

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Paediatric Ophthalmology

Strabismus

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Retinoblastoma

Retinopathy of Prematurity

Nasolacrimal System Defects

Ophthalmia Neonatorum

Congenital Glaucoma

Ocular Trauma

Blunt Trauma

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Hyphema

Blow-Out Fracture

Chemical Burns

Ocular Drug Toxicity

Common Medications

Landmark Ophthalmology Trials

References

OP22

OP2

OP3

OP23

OP26

OP5

OP5

.OP7

OP9

OP29

OP10

OP33

OP12

OP33

Conjunctiva

Pinguecula

Pterygium

Subconjunctival Hemorrhage

Conjunctivitis

Sclera

Episcleritis

Sderitis

Cornea

Foreign Body

Corneal Abrasion

Recurrent Erosions

Corneal Ulcer

Herpes Simplex Keratitis

Herpes Zoster Ophthalmicus

Keratoconus

Arcus Senilis

Kayser-Fleischer Ring

The Uveal Tract

Uveitis

Lens.

Cataracts

Dislocated Lens (Ectopia Lentis)

OP14

.OP37

OP16

OP17

OP41

OP43

OP20 OP44

OP46 OP21 r n

OP48

+

OP1 Ophthalmology Toronto Notes 2023

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Acronyms

AJON anterior ischemic optic

neuropathy

age-related macular

degeneration

best-corrected visual acuity

branch retinal artery occlusion

branch retinal vein occlusion

cup-to-disc ratio

cytomegalovirus

central retinal artery occlusion

central retinal vein occlusion

diopter

diabetic retinopathy

LASIK laser-assisted in situ

keratomileusis

multiple sclerosis

OCT optical coherence tomography ROP

OHT ocular hypertension

PACG primary angle-closure glaucoma SPK

granulomatosis with polyangiitis PDR proliferativediabetic retinopathy TED

giant papillary conjunctivitis

Heidelberg retinal tomography PERRLA pupils equal,round,and reactive VA

to light and accommodation

POAG primary open-angle glaucoma

photorefractive keratectomy

PVD posterior vitreous detachment

EBV Epstein-Barr virus

extraocular movement

fluorometholone

Goldmann applanation

RA rheumatoid arthritis

relative afferent pupillary defect

retinal detachment

retinopathy of prematurity

retinal pigment epithelium

superficial punctate keratitis

thyroid eye disease

transient ischemic attack

visual acuity

vascular endothelial growth

factor

yttrium aluminum garnet

EOM RAPO

AMD FML MS RD

GAT

BCVA

BRAO

BRVO

tonometry RPE

GCA giant cell arteritis

GPA

CDR GPC PDT photodynamic therapy TIA

CMV HRT

CRAO

CRVO

INO internudear ophthalmoplegia

intraocular lens

VEGF

I0L

D IOP intraocular pressure PRK YAG

DR

Basic Anatomy Review

Lateral View Superior View

.

.. -Tendon of superior rectus muscle Anterior chamber

Iris Cornea-

,

Ciliary muscle

and body

_Bulbar

. conjunctiva

Retina

.\Choroid mi Lens

,

^3»

Meibomiai

gland . 1 Ciliary muscle

Jr and body Tendon of lateral

rectus muscle k Sclera 5 A Tendon of medial

rectus muscle Eyelash.

_l

,ens

Cornea

—Optic Choroid nerve

Palpebral w

conjunctiva lyfCtinaTbloDd vessels

-4

CM i conjunctiva

Bulbar A'

'"W a

7

.Tendon of inferior rectus muscle Retinal blood vessels f

Conjunctival fornix t>

Rgure 1. Anatomy of the eye

RETINAL LAYERS (10)

1. Inner limiting

membrane

2. Nerve fibre

layer

3. Ganglion cell

layer

CELL TYPES

-Vitreous humour

LIGHT RAYS

Optic nerve fibres

Ganglion cells

4. Inner plexiform

layer

—Amacrine cells

5. Inner nuclear

layer -Bipolar cells

—Horizontal cells

G. Outer plexiform

layer

7. Outer nuclear

layer —Rod nuclei

—Cone nuclei

8. Outer limiting

membrane

9. Photoreceptor

layer

Rod cells

Cone cells

10. Retinal

pigmented Pigmented cells

Bruch's membrane

Choroid

epithelium +

*

> MotionPhachanNa 2016. alter Sarah A. Kirn 2006

Figure 2. Layers of the retina

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Lacrimal gland

Superior lacrimal punctum

iuperior canaliculus

nferior canaliculus

Meibomian JS

-

ff 3

gland r

undus of Inferior lacrimal punctum lacrimal sac

Nasolacrimal

duct

Valve of Hasner

Inferior

concha

3-

0

Figure 3. Tear drainage from the eye (lacrimal apparatus)

Differential Diagnoses of Common

Presentations

Loss of Vision

Loss of Vision

I

i

Transient Chronic (weeks to months)

(seconds to hours)

Acute ( seconds todays)

i I i

• TIA/ Cornea/Anterior Vitreous/Relina/

Optic Nerve

• Vitreous

hemorrhage

Cortical/Other Cornea/Anterior

• Occipital Segment

infarction/ • Corneal

hemorrhage dystrophy/ • DR

• Conical scarring/edema • Retinal vascular induced

blindness * Refractive error insufficiency (sildenafil,

• Functional * Cataract * Compressive amiodarone)

(non-organic,

* Glaucoma optic neuropathy • Nutritional

diagnosis of (intracranial mass,deficiency

exclusion) orbital mass) • Papilledema

• Intraocular

neoplasm

* Retinitis

pigmentosa

Vitreous/Retina/

Optic Nerve

• AMO

Cortical/Other

• Pituitary

adenoma

amaurosis Segment

lugax • Corneal edema

• Migraine

with auia

• Hyphema • Medication-

(blood in anteriot • RD

chamber)

• Acute angleclosure

glaucoma

• Trauma/loreign

• Retinal artery/

vein occlusion

• Acute macular

lesion

• Optic neuritis

• GCA

• AION

body

Figure 4. Loss of vision

Red Eye

Table 1. Common Causes of Red Eye

Common Causes

Lids/Orbit/Lacrimal System

Hordeolum/chalazion

Blepharitis

Entropion/ectropion

Foreign body/laceration

Dacryocystitis/dacryoadenitis

Conjunctiva/Sclera

Subconjunctival hemorrhage

Conjunctivitis

Dry eyes

Pterygium

Episderitis/sderitis

Preseptal/orbital cellulitis

Cornea

Foreign body (including contact lens)

Keratitis

Abrasion, laceration

Ulcer

Other

Trauma

Postoperative endophthalmitis

Pharmacologic (e.g.prostaglandin analogues)

r "i

L J