obs and gyn orders
TRANSCRIPT
med-ed-online 2008
Sample Obstetrics Orders By:
Mitra Ahmad Soltani
References: 1-Williams Obstetrics / 22nd Edition/ MC. Graw Hill/ 20052-Novak’s Gynecology/ 13 th Edition/ Williams and Wilkins/ 20023-TE Linde’s (Operative Gynecology) 9 th Edition / Williams and Wilkins / 2003 4-Iranian Council for Graduate Medical. Education. Promotion and board Exam questions.(2000-2007)5- www.cdc.gov/asthma/speakit/slides/managing_asthma.pptwww.cdc.gov/asthma/speakit/slides/managing_asthma.ppt 6- An extract from Tan T& Yeo G. IUGR. Current Opinion in Obstetrics An extract from Tan T& Yeo G. IUGR. Current Opinion in Obstetrics and Gynecology 2005, 17: 135-142and Gynecology 2005, 17: 135-1427-Panda S . IUGR. Department of Obstetrics & Gynecology Medical 7-Panda S . IUGR. Department of Obstetrics & Gynecology Medical College of India 2002College of India 20028-med-ed-online.org/rcurricula/med_decision_making.8-med-ed-online.org/rcurricula/med_decision_making.
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Recommended laboratory tests in the initial prenatal care visit
1. Hct, Hb2. U/A,U/C3. BG,Rh4. Pap smear5. Antibody screen6. Rubella status7. Syphilis screen8. Hbs Ag9. Offer HIV testing
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Impression: normal labor
• General: condition/position/diet• Lab: CBC, BG, Rh, U/A, reserve of 2 units of PC• IV : 1000cc Ringer at KVO
for long labors 1/3,2/3 60-120mL/h• PO:-• OTHER: Control of vital sign q4hrs, control of
FHR q30 min in 1st stage of labor q15 min in the 2nd stage, amniotomy if fetal head is fix
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Impression: NVD+Epi
• General: condition/position/diet• Lab: F/U CBC• IV : 1000cc Ringer +20 units of oxytocin • PO:
cap cephalexin 500 mg qidTab ferrus sulfate daily,cap mefenamic acid TDS
• OTHER: Control of vital sign q15 min for the1st hr then q1hr for 4 hrs then as routine
• Inform if BP is abnormal/bleeding is excessive/ no voiding after 4 hrs
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7 contraindications for lactation
• Alcohol and Drug abusers• Galactosemia of the newborn• HIV• Active, untreated TB• Ongoing breast cancer treatment• Cytomegalovirus• Hepatitis B virus (not contraindicated if hepatitis
B immune globulin is given to infants of seropositive mothers)
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10 drugs contraindicated in lactation
• Bromocriptine• Cocaine• Cyclophosphamide• Cyclosporine• Doxorubicin• Lithium• Methotrexate• Phencyclidine
• phenindione• Radioactive iodine and other radiolabled elements
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IMP:Mastitis (out patient)
• Lab:, Milk culture , CBC diff
• PO: dicloxacillin 500 mg qid 7-10 days
• Or erythromycin to penicillin sensitive women
• Or vancomycin to MRS
• OTHER: Control of vital sign q 4 hrs, pumping breasts until nursing can be resumed
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Postoperative infection
• General: condition/position/diet
• Lab: CBC diff, MP, WW, B/C X2, U/A , U/C,CXR,BUN/Cr
• IV : 1000cc Ringer at KVOAMP clindamycin 900 mg iv TDS +gentamicin im
80mg stat then 60 mg TDS
add amp ampicillin 2gr iv qid and pelvic exam and imaging study if fever persists 72 hours,
OTHER: Control of vital sign hourly
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Imp:chorioamnionitis
• General: condition/position/diet=NPO• Lab: CBC diff, MP, WW, B/C X2, U/A ,
U/C,CXR,BUN/Cr • IV : 1000cc Ringer +10 units of oxytocin start at 2 drops /min, add 4 drops every 15 min if FHR
and contractions are normal Amp ampicillin 2gr iv qid +gentamicin im 80mg stat then
60 mg TDS AMP clindamycin 900 mg iv TDS for allergic women to
penicillin(continue antibiotics after delivery until the mother is a febrile
OTHER: Control of vital sign hourly
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Sepsis syndrome• General: condition/position/diet• Lab: CBC diff, hct, MP, WW, B/C X2, U/A , U/C ,
CXR, BUN/Cr• IV :
AMP clindamycin 900 mg iv TDS +gentamicin im 80mg stat then 60 mg TDS
add amp ampicillin 2gr iv qid and pelvic exam and imaging study if fever persists 72 hours
Amp dopamine 5 mcg/kg/min or dubotamine iv drip
OTHER: Control of vital sign hourly ,oxygen therapy, correct acidosis, excise infected tissue, fix foley ,
Low output cardiogenic shock-1
SBP<70 mmHg +sign/symptoms of shock:Noreinephrine IV 0.5 to 30 mcg/min
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Low output cardiogenic shock-2
SBP=100-70+sign/symptoms of shock:DOPAMINE: 5-15 mcg/kg/min IV
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Low output cardiogenic shock-3
SBP=100-70 no sign/symptoms of shock:Dobutamine: 2-20 mcg/kg/min IV
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Low output cardiogenic shock-4
SBP>100NTG=10-20 mcg/min IV Consider SNP: 0.1-5 mcg/kg/min IVACEinh. if SBP is not<30 mmHg below baseline.
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Glasgow Coma Scale
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Eye Opening 4 Spontaneous
3 To Voice
2 To Pain
1 Nil
Verbal Response 5 Orientated
4 Confused
3 Words
2 Groans
1 Nil
Motor Response 6 Obeys Commands
5 Localizes Pain
4 Withdraws from Pain
3 Flex
2 Ext
1 Nil
IMP: R/O abruption• Condition/position/diet:NPO• Lab: CBD-BG-Rh-U/A-U/C-PT-PTT-Fib-FDP-D-Dimer-• Prep 4 units of crossmatched packed red blood cells• Continuous high-flow supplemental oxygen • One or 2 large-bore IV lines with normal saline (NS) or
lactated Ringer (LR) solution+10 units of oxytocin in 1 lit of ringer start at 2 drops/min add 2 drops every 15 min if fetal heart rate and uterine contractions are favorable.
• perform amniotomy • Closely observe the patient. Monitor vital signs and urine
output, fetal heart rate and uterine height measurement.• Prepare OR for emergent C/S
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Class 1 Class 2 Class 3 Class 4
Blood LossVolume (mls) in
adult750mls 800 - 1500mls 1500 - 2000mls >2000mls
Blood Loss% Circ. blood
volume<15% 15 - 30% 30 - 40% >40%
Systolic Blood Pressure
No change Normal Reduced Very low
Diastolic Blood Pressure
No change Raised ReducedVery low /
Unrecordable
Pulse (beats /min)Slight tachy-
cardia100 - 120 120 (thready) >120 (very thready)
Capillary Refill Normal Slow (>2s) Slow (>2s) Undetectable
Respiratory Rate Normal Normal Raised (>20/min) Raised (>20/min)
Urine Flow (mls/hr)
>30 20 - 30 10 - 20 0 - 10
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Estimated blood loss
Suitable fluid regimes
1000 mls 3000 mls crystalloidor
1000 mls colloid
1500 mls1500 mls crystalloid & 1000mls
colloidor
4500 mls crystalloid
2000 mls1000 mls crystalloid, 1000mls colloid
& 2 units bloodor
3000 mls crystalloid & 2 units blood
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Infection Suggested oral adult dose
Price
Acute cystitis Trimethoprim 200 mg bd or Augmentin 625 mg tid or Nitrofurantoin 50 mg qid Nalidixic acid 500 mg qid
TRIMETHOPRIM 100MG TAB= 66 Rls.CO-AMOXICLAV 625 (500/125) TAB = 2,970 Rls.NITROFURANTOIN 100MG TAB= 57 Rls.
Acute pyelonephritis (pre- hospital admission)
Ciprofloxacin 750 mg bd
CIPROFLOXACIN-EXIR® 250MG TAB = 350 Rls.
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PE
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Is PaCO2 increased?
Yes=hypoventilationIs PAO2-PaO2
increased?
Is PAo2-PaO2 increased?
Hypoventilation alone
Yes=hypoventilation +another mechanism
Decreased inspired PO2
If yes then find outif low PO2 is correctable with
O2?
Yes=V/Q mismatch Shunt
ABG reading
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Check if the blood is from an artery (CO2=15+HCO3)
Calculate Anion Gap(AG=Na – (Cl +HCO3)
Calculate if the response is compensatory or not
If there’s no significant AG (more than10-12), then it must be either RTA or GI loss. In GI loss this formula
applies => Urinary Cl>Urinary Na +K
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PE, DVT
• IV heparin 5000 unit q4h
• Check of PTT Q6h
• Discharge with warfarin 5 mg /day for 4-6 months
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PTT (sec) Heparin Dosing Instructions Recheck PTT
Repeat Bolus
DoseHold Infusion
Change Rate of Infusion
units minutes ml/h (units/h)
50 - 59 0 0+2 cc/h
(+80 u/h)6 h
60 - 85 0 0 no change next am
86 - 110 0 0-2 cc/h
(- 80 u/h)next am
< 50 5000 0+4 cc/h
(+160 u/h)6h
>110 0 60-4 cc/h
(- 160 u/h)6h
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IMP:PLP before 37 weeks out patient:(contractions 4 in 20 min or 8 in 60 min +progressive change in cervixcervical dilation of more than onecervical effacement of more than 80 % or greater)
if:Check of contractions:+
U/A, U/C: -Fern:-
Then: Hydrate and sedate
Stop of contractions: dischargeWith:isoxsuprine 10 mg TDS for 10 days
Contractions persist: hospitalizeNext slide
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IMP:PLP before 37 weeks, hospitalized• General: condition/position/diet• Lab: CBC, BG, Rh, U/A, U/C, fern, reserve of 2 units of PC• IV : 1-1000cc Ringer free 2-MgSO4 (4 gr) in 200cc DW5% in 20 min then 20 gr in 1000cc
infused in 100cc/hrs (check of I/O, RR,DTR, prep CPR set- I/O with measure)
3-Amp pethidine 25 mg iv 25 mg im4-Amp ampicillin 2 gr IV qid 5-Amp erythromicin 400 mg QID 6- Amp betamethasone 12 mg im, repeat after 24 hrs for GA below
34 wks • OTHER: Control of vital sign q4hrs, Inform if LP, leakage, VB, ab VS
or FHR
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Contraindication to tocolysis
• Acute fetal distress
• Chorioamnionitis
• Eclampsia or sever preeclampsia
• Fetal demise
• Fetal maturity
• Maternal hemodynamic instability
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Contraindication for beta mimetics
Maternal
• cardiac disease
• Diabetes
• Thyrotoxicosis
• HTN
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Contraindication for MgSO4
• Hypocalcemia
• Myasthenia gravis
• Renal failure
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Contraindication for indomethacin
• Asthma
• CAD
• Gastrointestinal bleeding
• Oligohydramnios
• Renal failure
• Suspected fetal cardiac or renal anomaly
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Dosage of Ritodrine or Terbutaline for tocolysis
• 50-100 mcg/min increase by 50 mcg/min every 10 min
• max dose:350mcg/min
If labor is arrested continue the infusion for at least 12 hrs
• SC:
250 mcg q3-4 hrs
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Endocarditis Prophylaxis
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IMP: Hyperemesis Gravidarum
• General: condition/position/diet• Lab: CBC, BG,Rh, U/A, U/C, k, Na, BUN/Cr, TFT• reserve of 2 units of PC• IV : 3000cc(DW10%+ DW5%+1/3,2/3)divided in
24 hrs • AMP Promethazine 25 mg iv qid• Amp plazil 10 mg qid • Tab navidoxin daily • OTHER: Control of vital sign q4hrs, daily weight,
check of I/O with measure sono OB
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Suspecting Acute Hepatitis
• HBS Ag, Ab
• Anti HBC (IgM)
• ANTI HAV (IgM)
• Anti HCV
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Suspecting Chronic Hepatitis
• HBe Ag, Ab
• HBS Ag ,Ab
• Anti HCV
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IMP: Pyelonephritis
• General: condition/position/diet• Lab: CBC diff, BG, Rh, U/A,U/C, k, Na, BUN/Cr, WW,
MP,B/CX2 (Repeat of U/C after initiation of antibiotics if positive then
kidney sono)• reserve of 2 units of PC• IV : 1000cc DW5% free • AMP keflin 2 gr stat then 1 gr q6h• Amp gentamicin 80 mg im stat then 60 mg tds • OTHER: Control of vital sign q4hrs, control of FHR,FAD
chart , check of I/O with measure, sono OB
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GFR=(140-age)/72x PCr x 85% for females
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Blood sugar
• For pregnancy
Ab>105 FBS
Ab>120 2hr PP
POSTPARTUM
Ab>140 FBS
Ab>200 2hr PP
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IMP: Diabetes
• General: condition/position/diet =diabetic• Lab: CBC diff ,BG, Rh, U/A,U/C, BUN/Cr,
BS(FBS, 10AM,4 PM,8PM), (PT, PTT, Fib) (reserve of 2 units of PC
• IV :Ringer at heparin lock• Insulin morning (10 units NPH +4 Reg)• Insulin afternoon(4 NPH+4 Reg)
• OTHER: Control of vital sign q4hrs, control of FHR, FAD chart , NST, sono OB, ophthalmologic consultation
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• For each increase in BS more than 200 add 2 units to regular to each 50 mg of BS
• Insulin is used before breakfast and evening meal
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IMP: mild preeclampsia
• General: condition/position/diet =low salt,high prot• Lab: CBC ,BG, Rh, U/A,24hr urine (prot,cr,vol), BUN/Cr,
PT,PTT,Fib, ALT,AST,Al P, Bil (T, D)
• reserve of 2 units of PC• IV :Ringer at heparin lock
• OTHER: Control of vital sign q4hrs, control of FHR, FAD chart , NST, sono OB, daily weight inform if BP>160/110, blurred vision, head ache, epigastric pain, seizure
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IMP: Severe preeclampsia• General: condition/position/diet =NPO• Lab: CBC ,BG, Rh, BUN/Cr, PT, PTT,Fib ,ALT,AST,Al P, Bil (T, D) • prep 2 units of PC• IV :Ringer 1000cc +10 u of oxytocin• if BP>160/110,blurred vision, head ache, epigastric pain, seizure
then amp hydralazine 5 mg iv prn
MgSO4 (4 gr) in 200cc DW5% in 20 min then 10 gr(1/2) im in each buttock then 5 gr im q4h
If platelet is below 100000 then 20 gr in 1000cc infused in 100cc/hrs (check of I/O,RR,DTR, prep CPR set with 2 gr 20% MgSO4 ready) +Amp Dexa 6 mg im bid for 4 doses
OTHER: Control of vital sign q15 min , control of FHR, fix foley,
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Emergency C/S
• Prep 2 units of pc
• Amp keflin 2 gr iv
• Prepare for C/S
• Transfer to OR
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The night before elective C/S
• CBC, BG, Rh, (FBS,BUN/CR, CXR, ECG)
• Prep 2 units of pc
• NPO from 12 am
• Iv Ringer KVO
• Check of FHR and contractions
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8 hours after C/S
• fair, RBR, surgical diet, • IV 2 lit Ringer• Continue keflin• Supp bisacodyl 2 stat then tab bisacodyl
bid• Foley DC, • I/O DC• F/U CBC
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24 hours after C/S
• Condition good ,RBR, reg diet,
• IV as heparin lock
• Continue keflin
• tab bisacodyl bid
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36-48 hours after C/S
• Remove dressing
• Discharge with
Cap cephalexin 500 mg qid
Cap mefenamic acid 500 mg tds
Cap hematinic (according to Hb)
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Diabetic C/S
NPO from 12 am Prep 2 units of PC 1000 cc Ringer IV fluid q8 hrs the night before surgery
Amp keflin 2 gr iv stat half an hour before surgery• Before operation: 10 units of regular +1000 cc DW5%
150cc/hr• Check of BS q6h after operation
Inform in cases of ROM or bleeding or pain
Asthma management
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Heavy vaginal bleeding in a 14 year old girl with Hb value of 7 gr/dl and normal coagulation tests and platelets and pelvic sonography:
Conjugate estrogen 25-40 mg IV q6h or Conjugated estrogen 2.5 mg q6h PO until bleeding is controlled followed by medroxy progesterone
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Prolonged spotting in a 14 year old anemic girl
Low dose OCP 21 days for 3-6 cycles
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DUB in a 16 year old girl with stable vital signs:
Monophasic OCP q6h for 7 days+ Iron supplements
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Recurrent abortion tests
• Karyotype
• HSG
• Luteal phase biopsy of endometrium
• TSH and prolactin level
• ACL ab
• LAC
• CBC
Abortion without fever:
Doxy 100 mg bidortetracycline 250 mg qid for 5-7 days
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Beta HCG below 2000+no visible intrauterine sac+mass in tube below 3.5 cm______________________control of beta HCG q 48 hA-If a dead IP is confirmed (beta HCG increase less than 50% or below 1000mIu/mL- P below 5 ng/mL + visible intrauterine sac) then curettage B-If EP is confirmed (beta HCG more than 2000 and mass >3.5 cm) then laparascopyC-If a dead IP and EP is confirmed (beta HCG more than 2000 and mass < 3.5 cm) then MTXFETUS SHOULD BE VISIBLE ON DAY 45 OF GESTATION
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Indication of MTX for EP
• Hemodynamic stability
• No intra uterine pregnancy
• Max sac diameter not equal or more than 4 cm
EP
• Adenexal mass< 3.5 cm-> MTX
• adenexal mass=> 3.5 cm -> laparascopy
• uncertain US + beta HCG increase less than 50% -> D&C
• unstable conditions->laparatomy
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