Before Your First: Hysteroscopy

Before Your First: Hysteroscopy

Headed into the OR for your first hysteroscopy? In this episode, we walk through everything you need to know before you scrub in — from indications and pre-op preparation to OR equipment, distension media, fluid deficit management, and how to handle complications when they arise. I. Introduction & Learning Goals Purpose: Guidance for an intern's first hysteroscopy in the OR. Objectives: Review indications, pre-op preparation, OR setup/equipment, fluid media, and complications. II. Indications for Hysteroscopy Diagnostic Hysteroscopy: * Abnormal uterine bleeding (AUB) or postmenopausal bleeding * Infertility workup * Evaluation of abnormal imaging findings Operative Hysteroscopy: * Polypectomy (removal of polyps) * Myomectomy (removal of submucosal fibroids) * Septum resection * Lysis of adhesions (Asherman syndrome) * Foreign body removal (e.g., "lost" IUD) III. Pre-Operative Preparation Chart Review Checklist: * Indication: Understand the clinical reason for the procedure * Imaging (US/MRI): Confirm uterine size (to avoid over-dilating) and location of pathology * Comorbidities: Check cardiac, renal, and pulmonary history to set fluid management thresholds * Cervical History: Assess risk for stenosis (prior procedures or menopause) * Menstrual Cycle: Check current phase (bleeding can obscure visualization) Patient Counseling (Benefits & Risks): * Benefits: Superior diagnostic sampling and therapeutic symptom relief * Standard Risks: Pain, bleeding, infection (low risk) * Specific Risks: Uterine perforation (may require laparoscopy if energy was used or if there is concern for bowel injury) IV. Equipment & OR Setup The Hysteroscope Components: * Telescope: The lens (0-degree for forward viewing vs. 30-degree for lateral angles) * Sheaths: Inner and outer sheaths to house the telescope and allow fluid flow * Inflow/Outflow Ports: For fluid delivery and drainage (use under-the-butt drapes to catch fluid for deficit calculation) * Light Source: Warning — becomes extremely hot; keep away from drapes/patient * Camera System & Monitor * Working Channel: For operative instruments (graspers, scissors) V. Distension Media (Fluids) Isotonic Solutions (Preferred): * Normal Saline: Compatible with bipolar electrosurgery; same osmolality as blood Hypotonic Solutions: * Glycine (1.5%), Sorbitol (3%), Mannitol (5%) * Used only for monopolar surgery; higher risk of hyponatremia Fluid Deficit Management: * Definition: The difference between fluid into the uterus vs. fluid recovered * ACOG Threshold: Max 2,500 mL for isotonic; however, many surgeons stop at 1,500 mL (or 750–1,000 mL for high-risk patients) VI. Procedural Steps & Tips * Cervical Dilation: Can use mechanical dilators or "hydrodilation" using fluid pressure through the scope * Tenaculum Tip: Take a "sturdy bite" of the cervix to prevent tearing/lacerations * Pressure Management: Keep intrauterine pressure lower than the patient's Mean Arterial Pressure (MAP) to limit fluid extravasation into the body VII. Complications * Uterine Perforation: Often occurs during dilation; recognized by a "loss of resistance" * Fluid Overload: Can lead to hyponatremia, distributive shock, or flash pulmonary edema * Hemorrhage: More common in operative cases (3% for myomectomy); manage with massage, uterotonics, or intrauterine balloons * Vasovagal Reaction: Can occur during cervical manipulation or distension * Gas Embolism: Rare; more common with older CO₂ distension methods Resources: * ACOG Technology Assessment: Hysteroscopy [https://www.acog.org/clinical/clinical-guidance/technology-assessment/articles/2018/09/hysteroscopy] * UpToDate: Hysteroscopy – Managing Fluid and Gas Distending Media [https://www.uptodate.com/contents/hysteroscopy-managing-fluid-and-gas-distending-media] * AAGL – Advancing Minimally Invasive Gynecology Worldwide [https://www.aagl.org/] About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Mahima Krishnamoorthi, MD – Gyn/Ob resident at Johns Hopkins Hospital. She attended Stanford University for undergrad and graduated from the Johns Hopkins School of Medicine. Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

Before Your First: Day With Fetal Therapy

Fetal therapy is a subspecialty of maternal-fetal medicine focused on treating fetal disease before birth — from prenatal cures (anemia, TTTS) to improving outcomes (myelomeningocele, CDH), optimizing conditions at birth, and transplacental therapy (SVT, congenital heart block). In this episode, Dr. Michelle Kush walks us through the major fetal therapy procedures you may encounter as an OB/GYN resident and what your role will be. Topics Covered: * What Is Fetal Therapy? – Subspecialty of MFM treating fetal conditions before birth. Contact the fetal therapy team at 844-543-3825. * Fetal Anemia and Intrauterine Transfusion * Busiest fetal transfusion center in the Mid-Atlantic (600+ transfusions to date). * Most common indications: alloimmunization, parvovirus infection, hydrops/hereditary spherocytosis. * Performed on L&D once fetus reaches viability, with betamethasone course completed. * Risks: preterm labor, PROM, fetal bradycardia, emergent delivery (<1%). * General care path: arrive → H&P → OB anesthesiology → NPO, IVF, continuous fetal monitoring → transfusion (usually in triage room) with OR, anesthesiology, and NICU on standby. * Post-transfusion: Continuous monitoring (fetus is paralyzed — change mother's position for decels). Advance to clears at 1 hour if no contractions and reassuring tracing. Earliest discharge at 2 hours if Category I tracing and fetal movements have returned. * Twin-to-Twin Transfusion Syndrome (TTTS) * Occurs in monochorionic pregnancies — unequal sharing of volume between donor and recipient twins. * Fetoscopic laser ablation of placental vascular anastomoses offered for Stage 2+ (or progressing Stage 1), performed 16–26+6 weeks. * Risks: preterm labor, PROM, membrane separation, demise of one or both fetuses, bleeding, maternal transfusion (<2%). * Pre-op: consents in the Center, H&P, OB anesthesiology, NPO, IVF, Foley catheter prior to OR. * Post-op: magnesium 2 g/hr (titrate up by 0.5 g/hr for >6 contractions/hr). POD 1: stop mag, remove Foley, AM CBC, regular diet, ultrasound in Center, may discharge home. * Myelomeningocele (MMC) Closure * Performed 24–26 weeks for isolated anomaly with normal genetics (open or fetoscopic approach). * MOMs trial showed: less hindbrain herniation, decreased/delayed shunt placement, improved ambulation at 30 months. * Maternal risks: preterm delivery, PROM, uterine incision complications. * Admit night prior. Morning of: A-line placed, indomethacin at 6 AM, magnesium started, Foley placed. * Post-op: highest risk for pulmonary edema — strict I&O, incentive spirometry is a must, continuous fetal monitoring, epidural for pain, SCDs in place. If concerns: see the patient, listen to lungs, check I&O, and CALL. * POD 1: AM labs (CBC, CMP), continue indomethacin/heparin/SCDs/IS. Remove A-line if all agree. Mag and Foley discontinued. Transition to PO pain control (Tylenol, Dilaudid, gabapentin, Flexeril, abdominal binder). * Fetal Arrhythmias and Transplacental Therapy * Most common admission: fetal SVT (FHR >180 bpm for more than 10% of observation time). * Indications for transplacental therapy: tachycardia ≥180 bpm with biphasic DV, tachycardia ≥280 bpm regardless of duration, or SVT with fetal hydrops. * May need 24 hours of continuous monitoring to determine if transplacental therapy is needed. Risk for hydrops and fetal death. * Most commonly treated with flecainide; additional agents include digoxin and amiodarone. * Maternal baseline: EKG and CMP with ionized Ca, then continuous cardiac monitoring while initiating. Must have normal EKG indices (PR ≤0.2 sec, QRS ≤0.12 sec, QTc ≤0.47 sec). About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Michelle L. Kush, MD – Assistant Professor, Maternal-Fetal Medicine, Center for Fetal Therapy in the Department of Gynecology and Obstetrics at Johns Hopkins. Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

Before Your First: L&D Triage Evaluation

Your first Labor & Delivery triage shift is coming up — here's how to handle it. In this episode, we walk through the full workflow: from chart-checking a patient before you walk in the room, to gathering a focused history, performing your exam, staffing efficiently, and writing a solid triage note. Topics Covered: * Where to Start * Chart check the patient — age, parity, gestational age, medical and OB problems. * Confirm dating with your own eyes. Trust but verify. * Skim prior encounters for chronic conditions and what's worked before. * Check if they're up to date on routine OB care (e.g., GBS swab at 36 weeks). * Start a note using premade templates to save time. * Bring your ultrasound, stethoscope, mask, and something to keep notes. * If the patient is on the NST, don't wait for it to complete before performing your sono. * Gather a focused but detailed history, then do a focused physical exam. Perform a pelvic exam as indicated (with patient consent), with or without your chief. * Most Common Chief Complaints * Rule out labor / preterm labor, general abdominal pain * Rule out PPROM / SROM * Decreased fetal movement (DFM) * Rule out PIH / preeclampsia * Vaginal bleeding/spotting or abnormal discharge * Urinary symptoms, nausea/vomiting, constipation, headaches, URI symptoms * How to Staff * Gather all data before staffing — evaluate the NST, review your slides, listen to lungs if needed. * Follow the standard SOAP format: Age, parity, GA, chief complaint → HPI → vitals, PE (including SSE/SVE) → your plan. * Think through: labs needed, ECG, formal sono, how long to monitor pressures, admission vs. discharge, and whether other services need to be consulted. * Your plan doesn't need to be 100% right — that's what intern year is for. Track patterns so you can apply them next time. * Closing the Loop with the Patient – Update them as things progress. If you don't know the answer, say so, then find out (UpToDate, Open Evidence, institutional resources, your chief/senior). * Writing Your Triage Note – Thorough but concise. Think through the differential. Update the note as labs return and the plan is finalized. Use dictation or EMR AI tools. Have your chief review notes the first few weeks. * After the Visit – Update the patient's problem list with any new diagnoses (e.g., pyelonephritis, gestational hypertension). About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Ore Afon, MD – Gyn/Ob resident at Johns Hopkins Hospital. She attended Cornell University for undergrad and graduated from the University of Toledo College of Medicine & Life Sciences. Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

Before Your First: Postmenopausal Bleeding Evaluation

Join this episode to learn about postmenopausal bleeding (PMB) — the incidence, the etiologies, and the diagnostic approach to a patient presenting with uterine bleeding after menopause. A special focus is placed on endometrial hyperplasia and endometrial malignancy, including associated risk factors and the use of transvaginal ultrasound and endometrial sampling in the evaluation. Critical evaluation of PMB is important as the leading concern is cancer until proven otherwise in this patient population. Keywords: Postmenopausal bleeding, Transvaginal ultrasound, Endometrial hyperplasia, Endometrial malignancy/cancer, Endometrial sampling Topics Covered: * Overview of PMB – Definition, incidence (5% of office GYN visits, 4–11% of menopausal patients), and why the leading concern is endometrial cancer until proven otherwise. * Etiologies * Polyp (~35%) – Localized overgrowths stimulated by estrogen; mostly benign but higher concern for malignancy/hyperplasia in PMB patients. * Atrophy (~30%) – Low estrogen leads to endometrial/vaginal atrophy, micro-erosions, and spotting. * Uterine Fibroid (~5%) – Less common postmenopausally; if a PMB patient has fibroids, still assume endometrial pathology. * Endometrial Carcinoma (6–14%) – Most common gynecologic cancer in the U.S. Type I (estrogen-driven, favorable prognosis) vs. Type II (high-grade, aggressive). * Endometrial Hyperplasia (with and without atypia) – May coexist with or progress to carcinoma in 30–50% of cases. * Other causes – Proliferative/secretory endometrium, medications (HRT, anticoagulants, tamoxifen, SSRIs), post-radiation, infection, and non-uterine sources. * Risk Factors for Malignancy – Increasing age, obesity, unopposed estrogen, tamoxifen, early menarche, late menopause, nulliparity, PCOS, Type 2 DM, Lynch syndrome, Cowden syndrome, and family history. * Diagnostic Approach * History and physical exam * Transvaginal ultrasound (TVUS) – Endometrial thickness measurement; normal <4 mm in postmenopausal women; sensitivity 94–97%. * Endometrial sampling – In-office EMB vs. OR-based hysteroscopy with D&C, including benefits, risks, and how to choose. * Follow-Up and When to Refer – Management by pathology result, when to proceed to HSC D&C, and indications for Gyn Oncology referral. Resources: * UpToDate: Approach to the Patient with Postmenopausal Uterine Bleeding [https://www.uptodate.com/contents/postmenopausal-uterine-bleeding] * ACOG Committee Opinion: The Role of Transvaginal Ultrasound in Evaluating the Endometrium of Women with Postmenopausal Bleeding [https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/the-role-of-transvaginal-ultrasonography-in-evaluating-the-endometrium-of-women-with-postmenopausal-bleeding] * ACOG Clinical Consensus: Management of Endometrial Intraepithelial Neoplasia or Atypical Endometrial Hyperplasia [https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2023/09/management-of-endometrial-intraepithelial-neoplasia-or-atypical-endometrial-hyperplasia] * APGO Topic #54: Endometrial Hyperplasia and Carcinoma [https://tools.apgo.org/wp-content/uploads/2016/05/TC54.pdf] * ASCCP Cervical Cancer Screening Guidelines [https://www.asccp.org/guidelines/] About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Emily Stock, MD – Chief resident in the Department of Gynecology & Obstetrics at Johns Hopkins Medicine. She is currently applying for GYN Oncology Fellowship. Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

Before Your First: Benign Gyn Clinic

Your first day in benign GYN clinic is fast-paced and can feel overwhelming. In this episode, we cover what to expect, what to review ahead of time, and practical tips for running an efficient, patient-centered clinic visit — even when you only have 15 minutes. Topics Covered: * What to Expect on Your First Day – A mix of new patients, annuals, return visits, and problem-based appointments. Common complaints include contraception, AUB, pelvic pain, abnormal discharge, STI testing, and post-op checks. Expect a fast pace and feeling slow at first. * What to Review Ahead of Time * Well woman visit guidelines * AUB basics (PALM-COEIN) and the initial workup * ASCCP guidelines (brief overview) * Contraceptive options and the Medical Eligibility Criteria app * Vaginal discharge workup — STI testing, wet prep * Tips for a Smooth, Efficient Clinic * Pre-chart! Check for recent ED visits, PCP discussions, last pap, imaging, STI results. * Document as you go — brief notes while talking, make them complete later. * Optimize your EMR — templates that make sense, favorite order sets. * Make eye contact. * Biggest Challenges and How to Overcome Them * Efficiency: Practice-focused HPIs. * Sensitive conversations: Sexual history, IPV screening, menses — be direct and compassionate. * Pelvic exam confidence: Be trauma-informed, narrate what you're doing, be quick and confident. Don't tell patients to expect pain. * Saying "I don't know": Explain your thinking, discuss with the attending, and come back. * Advice We Wish We'd Known – Your confidence in pelvic exams improves dramatically. Give it time. About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Adrianna Gorniak, MD – Gyn/Ob resident at Johns Hopkins Hospital in Baltimore, MD. She has a passion for all things gynecology, with a special interest in complex benign gynecology. Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.