Chapter 3: OB/GYN AND SOME STDs

OBSTETRICS

ORAL CONTRACEPTIVE PILLS (OCPs)

• ­Absolute Contraindications to oral contraceptive pills (OCPS): Pregnancy, liver disease, breast cancer, and breastfeeding at < 6 weeks.
• ­Relative Contraindications: Hypertension, uncontrolled hyperlipidemia
• ­Anticonvulsants interfere with absorption, so instruct the patient to use a backup method of contraception. Consider using an OCP with more ESTROGEN.

CONCEPTION

Fifty percent of all first-time pregnancies occur within 6 months of a girl/woman losing her virginity. Twenty percent of all pregnancies occur within the first month!

PRENATAL CARE (PNC)

Eight (8) prenatal care visits are considered adequate.

(DOUBLE TAKE) GBS SCREENING AND PROPHYLAXIS MADE EASY!

Here are some key points and PEARLS about GBS screening and prophylaxis.

• RECTOVAGINAL GROUP B BETA HEMOLYTIC STREPTOCOCCUS (GBS)SCREENING CULTURES: These are obtained at 36 to 37 6/7 weeks gestation.
• INTRAPARTUM ANTIBIOTIC PROPHYLAXIS (IAP): Intrapartum Antibiotic Prophylaxis (IAP) refers to antibiotics given to mom when she presents for delivery. If indicated, give IV penicillin, ampicillin or cefazolin at least 4 hours prior to delivery. The latest guidelines from the CDC may be viewed for some “light reading” by visiting www.pbrlinks.com/gbsprophylaxis.
• TO GIVE OR NOT TO GIVE INTRAPARTUM ANTIBIOTIC PROPHYLAXIS? IAP is indicated for any of the following scenarios:
  • Invasive GBS disease was present in a previous infant
  • Positive GBS was noted in the URINE at ANY TIME during THIS pregnancy (regardless of treatment and subsequent cultures)
  • Positive rectovaginal GBS screening culture noted at 36 to 37 6/7 weeks in THIS pregnancy
  • Unknown GBS status PLUS any of these:
    • < 37 weeks gestation
    • ROM > 18 hours
    • Intrapartum fever of >100.4 F
    • Positive intrapartum NAAT testing
• IAP is considered adequate when penicillin, ampicillin or cefazolin is administered > 4 hours prior to delivery.
• IAP is NOT indicated for GBS positivity in previous pregnancies or for C-sections done with intact membranes.

Managing Newborns

After the delivery, pediatricians must decide if a baby will need diagnostic evaluation, antibiotics and how long the baby should be observed in the hospital. A diagnostic evaluation includes CBC, blood culture, and chest x-ray (if there are any abnormal respiratory signs). Lumbar puncture and CSF culture should be considered for infants at the highest risk of infection and especially those with critical illness (if the procedure can be tolerated). If antibiotics are started, baby should be monitored for 48 hours. If there were never any signs of sepsis and cultures are negative, stop antibiotics after 48 hours. For a neonate born to a mom for whom IAP was indicated (or the GBS status was not known), the information below should help you decide how to treat the baby:

• INFANTS > 35 WEEKS
• BLOOD CULTURE + ANTIBIOTICS + CONSIDER LP FOR SICK/HIGH-RISK INFANTS: Signs of clinical illness
• BLOOD CULTURE + ANTIBIOTICS OR OBSERVE FOR 36-48 HOURS: Well-appearing, maternal intrapartum temperature > 38° (regardless of adequate vs inadequate IAP)
• OBSERVE FOR 36-48 HOURS: Well-appearing, normal maternal temp, inadequate IAP
• ROUTINE NEWBORN CARE: Well-appearing, normal maternal temp, adequate IAP
• INFANTS < 34 WEEKS
• BLOOD CULTURE + ANTIBIOTICS + CONSIDER LP FOR SICK/HIGH-RISK INFANTS: Preterm labor, prelabor ROM, OR any concern for intraamniotic infection
• BLOOD CULTURE + ANTIBIOTICS + CONSIDER LP FOR SICK/HIGH-RISK INFANTS: Induced labor + inadequate IAP OR concern for intraamniotic infection OR respiratory or cardiac instability
• NO ANTIBIOTICS + EITHER BLOOD CULTURE OR NO LAB EVALUATION
• Induced labor, adequate IAP, NO concern for intraamniotic infection, AND NO respiratory/cardiac instability
• Born by C-section for maternal/fetal indications with ROM at time of delivery