GYN-Contraceptives/Pregnancy Flashcards
How does Hormonal Contraception function?
Inhibits ovulation by inhibiting mid-cycle luteinizing hormone (LH) surge
Does hormonal contraception protects against STI?
No
Oral Contraceptive pills schedule or how to use?
Start on 1st day of menses
§ Take daily on schedule, 21-day pill pack + 7-day sugar
Types of OCP?
Estrogen + progestin or progestin alone (very compliant-becasue has to be taken at same time daily as ovulation can occur)
• Progestin alone safe in breastfeeding, ↓ side effects because
no estrogen
Pro’s of OCP’s
dysmenorrhea & menorrhagia • improves acne • ↓ PID, ectopic pregnancy • protection against ovarian cancer, endometrial cancer & osteoporosis
Cons of OCPs:
↑ risk of thromboembolism
• weight gain, nausea, headaches
• ↑ risk of gallstones, hypertension (HTN
Implants
Etonogestrel (Nexplanon)
• Lasts 3 years
Failure rate 0.05%
Injectable
Medroxyprogesterone (Depo Provera)
• Q3mo IM injection
• Failure rate 5%
Transdermal
Norelgestromin (Ortho Evra)
• On 3 weeks, off 1 week
• Failure rate 10%
Intravaginal
Etonogestrel/Ethinyl estradiol (Nuvaring)
• In 3 weeks, out 1 week
• Failure rate 7%
• Must be removed during intercourse & replaced within 3 hrs
• Must be a very compliant & comfortable with body
What is Intrauterine device (IUD)?
Mechanism not completely understood; spermicidal, elicits sterile
inflammatory response
o Does not affect ovulation
o Most effective method after sterilization & abstinence
What is the increase risk of an IUD?
↑ risk insertion-related PID (uterus is sterile but vagina is not sterile?)
Does IUD protects against sTI?
NO
Most effective method after sterilization & abstinence
Intrauterine device (IUD)
Types of IUD
Hormonal and Copper
Hormonal IUD?
Mirena, Kyleena, Liletta, Skyla)
• 3-6 years of protection depending on type
Copper IUD?
Paraguard-not hormonal
• 10 years of protection
Barrier methods?
Male & female condoms; Intravaginal device (diaphragm, sponge)
Male & female condoms
Female not very widely used
§ STI protection
§ Failure rate average 20%
§ Must know how to properly use
Intravaginal device (diaphragm, sponge)?
Must be left in place 6-24 hrs post-intercourse § ± STI protection § Failure rate 15% § Used with spermicide nonoxynol-9 § ↑ risk of toxic shock syndrome
Emergency Contraception?
Progestin-only
Ulipristol acetate
Copper IUD
When is progestin hormonal contraception prefer?
After pregnancy, estrogen may affect breast milk production and increases risk of thromboemolism (remember pregnancy alone is a risk)
Copper IUD
Most effective within 5 days of unprotected intercourse
Ulipristol acetate
30 mg dose
o Prescription only
o Most effective within 5 days of unprotected intercourse
Progestin-only
1.5 mg dose o Available over-the-counter (OTC) o No age restriction o Most effective within 72 hrs of unprotected intercourse o Side effect: nausea & vomiting
Definition of Infertility
failure to conceive after 1 year of regular unprotected intercourse
Female causes of Infertility
Anovulatory cycles
● Ovarian dysfunction
● Structural issues
Male causes of Infertility
40%
● Abnormal spermatogenesis/motility issues
Work-up & management of Infertility?
Semen analysis ● Endocrine evaluation (thyroid stimulating hormone [TSH], follicle stimulating hormone [FSH], prolactin) ● Anatomical evaluation (hysterosalpingogram) ● Reproductive assistance o Clomiphene to induce ovulation o Intrauterine insemination (IUI) o In-vitro fertilization (IVF)
Diagnosis of pregnancy
Serum human chorionic gonadotropin (hCG) can detect pregnancy as early as 5
days post-conception
● Serum levels double every 48 hours in normal pregnancy
● Urine hCG can detect as early as 14 days post-conception
● Naegele rule
o Expected date of delivery (EDD) = 1st day of last menstrual period (LMP) +
1 year - 3 months + 7 days
Serum levels hCG doubles every?
48 hrs
Maternal physiologic changes
Cardiovascular: ↑ heart rate (HR), ↑ cardiac output (CO), ↑ stroke volume (SV), ↓
blood pressure (BP), ↓ peripheral vascular resistance (PVR)
● Pulmonary: ↑ tidal volume, ↓ expiratory reserve
● Hematologic: ↑ blood volume, ↑ fibrinogen, ↓ hematocrit
● GI: ↑ gastric emptying time, ↓ sphincter tone
When is (Prenatal care) First appointment schedule during pregnancy?
6-8 weeks, then Q monthly
Initial labs of pregnancy for mom? Baby?
Mom: CBC, Rh factor, U/A, STI swab, HIV, Rubella & Hep B titers
Baby; Fetal heart tones by doppler: 10-12 weeks
Naegele rule
Expected date of delivery (EDD) = 1st day of last menstrual period (LMP) +
1 year - 3 months + 7 days
Pregnancy nutrition?
Prenatal vitamin with folic acid + iron, dietary
calcium, smoking
& alcohol cessation; avoid mercury-containing fish, uncooked food
(goodbye sushi🍣) & unpasteurized cheese (goodbye fancy cheeses
When is genetic testing recommended?
Recommended at 9-14 weeks
What is tested in genetic testing?
Pregnancy-associated plasma protein A (PAPP-A); Along with nuchal scan & b-hCG levels, can detect genetic disorders
Every visit of pregnancy what will be done?
weight, fetal heart tones, fundal height, urine dip for
glucose and protein
When is quad screen done? What is check during quad screen?
15-20 weeks: 𝛂-fetoprotein, 𝛃HCG, estriol, inhibin A
Trisomy 21
“2 up, 2 down”: ↑𝛃HCG, ↑ inhibin A ↓ 𝛂FP, ↓estriol
Trisomy 18
Trisomy 18 “still underage”: All four low
Open neural tube defect:
↑ 𝛂FP
Prenatal care at 10 weeks?
Fetal Heart Tones by doppler
Prenatal care at 18 weeks?
Quickening
Prenatal care at 18-20 weeks?
Ultrasound for full anatomic screen
Prenatal care at 20 weeks?
Fundal height at umbilicus
Prenatal care at 24-28 weeks?
Glucose Tolerance Test
Prenatal care at 18 weeks?
RhoGAM if mom (-) and dad (+/unknown)
Prenatal care at 36-37 weeks?
Group B strep screen
Rh incompatibility (Level 1)?
Rh (-) mom carrying Rh (+) baby may develop anti-Rh antibodies with any
fetal blood leak into maternal circulation.
● Ab then can attack fetal RBC of subsequent Rh(+) pregnancies causing
hemolysis
Prevention of RH incompatibility?
Prevention: Give RhoGAM at 28 weeks with Rh(-) mom, Rh(+)/unknown dad
● Give second RhoGAM at birth if baby is indeed Rh(+)
● Give RhoGAM after abortion, ectopic pregnancy, vaginal bleeding,
amniocentesis or any suspicion of blood mixing in Rh(-) moms
Sexual/physical abuse in pregnancy (Level 1)
Psychosocial discussions of support, safety at all prenatal appointments
● Women at higher risk for physical abuse during pregnancy
Abruptio Placentae (Level 1)?
Definition: Premature separation of a normally implanted placenta
S/S of Abruptio Placentae (Level 1)
S/S: Painful, dark red vaginal bleeding, abd pain, fetal distress
○ Remember symptoms from the name→ an “abrupt” ripping of the
placenta would be painful
DX of Abruptio Placentae (Level 1)
U/s, no pelvic exam
Tx of Abruptio Placentae (Level 1)
Mild: Inpatient monitoring
○ Moderate to severe: Deliver that baby
Breast Cancer (Level 1)?
#1 non-skin cancer in women, #2 most common cause of cancer deaths in women. Two main variants: Ductal and lobular
Risks of Breast Cancer (Level 1)?
↑ exposure to estrogen (early menarche, late menopause,
nulliparity), BRCA 1&2, 1º FH, age >65yr
S/s of Breast Cancer (Level 1)?
Painless, hard, non-mobile lump, most in upper outer quadrant
Late findings of reast Cancer (Level 1)?
Nipple retraction, nipple discharge, peau d’orange skin
thickening, axillary lymphadenopathy
DX of Breast Cancer (Level 1)?
Mammogram, U/S, biopsy
What % is breast Ca found by patient
90%
What age to a female pt being for the following : Screening: Mammogram, self breast exam, yearly clinical exam
> or - to 40
Screening: Mammogram guidelines, self breast exam, yearly clinical exam
ACS: Annual mammogram ≥ 40yo
● USPSTF: Mammograms q2y 50-74yo; q2y at 40yo if ↑risk; 10y prior to age
of 1º relative’s diagnosis
What is Ectopic pregnancy (Level 2)
Definition: Implantation of fertilized ovum outside uterus
● Areas of implant – Fallopian tube > abdomen > ovary, cervix; Top of “Do not miss” list of every woman of reproductive age presenting
with abdominal pain
Risks of Ectopic pregnancy (Level 2)
PID, IUD use, endometriosis
S/S Ectopic pregnancy (Level 2)
Classic triad of unilateral abdominal pain + vaginal bleeding +
amenorrhea (d/t pregnancy)
● If ruptured: syncope, signs of hemorrhagic shock
DX of Ectopic pregnancy (Level 2)
(+) pregnancy test, transvaginal U/S showing empty uterus
● Confirm with serial HCGs not doubling as expected
TX Ectopic pregnancy (Level 2)
Small, non-ruptured: Methotrexate (disrupts cell multiplication)
○ Ruptured, complicated: Surgery
○ Don’t forget RhoGAM for Rh negative mothers
○ Follow up 𝛃HCG is key!
Risks of Gestational diabetes (Level 1)
Prior h/o GD, multiple gestations, obesity, non-white ethnicity, prior
delivery of baby >9lb
DX of Gestational diabetes (Level 1)
Dx: 1h Glucose Challenge Test at 24-28wk
○ If BS ≥140mg/dL, confirm with 3h 100g Glucose Tolerance Test
TX of Gestational diabetes (Level 1)
Tx: Diet, exercise, meds to keep FBS <95 mg/dL (metformin, insulin)
If HTN < 20 weeks
→considered Chronic Hypertension
o Treat BP; monitor BP, urine for protein, and other symptoms as
pregnancy progresses
If HTN > 20 weeks + other symptoms
→considered Preeclampsia/Eclampsia
If HTN >20 weeks + no other symptoms
considered pregnancy induced
Preeclampsia
Occurs >20 weeks to 6 weeks postpartum
● Triad: HTN + proteinuria +/- edema
○ BP ≥ 140/90 on 2 occasions >4 hours apart AND
○ Proteinuria >300 mg/24hr or >1+ on dipstick
● Or in the absence of proteinuria, new-onset hypertension + new onset of:
○ Thrombocytopenia (platelets <100,000/microL)
○ Renal insufficiency (serum creatinine >1.1mg/dL)
○ Impaired liver function (elevated LFTs)
○ Pulmonary edema
○ Cerebral or visual changes
Severe Preeclampsia
Two severe BP values SBP ≥ 160 or DBP ≥ 110 obtained 15-60 minutes apart ● End-organs affected ○ Persistent oliguria <500mL/24hr ○ Progressive renal insufficiency ○ Unremitting headache/visual disturbances ○ Pulmonary edema ○ Epigastric /RUQ pain ○ LFTs 2x normal
Management Severe Preeclampsia
If GA ≥ 37 weeks → Deliver that baby
○ If GA < 37 weeks → Bedrest, daily weights, BP and proteinuria
monitoring
○ If <34 week, steroids for lungs
○ Magnesium to prevent seizures
○ Labetalol and/or hydralazine to lower BP (goal <160/110)
HELLP syndrome:
Severe pre-eclampsia + Hemolysis, Elevated LFTS, Low
Platelets
Eclampsia ?
Preeclampsia criteria + abrupt onset tonic-clonic seizures
Seizure timing: 25% antepartum, 50% intrapartum, 25% postpartum (most
within 48 hours but can be up to weeks postpartum)
S/S Eclampsia
Headache, visual changes, RUQ pain
Eclampsia TX?
Definitive treatment is delivery ○ ABCDs ○ Magnesium for seizures ○ Fetal monitoring while stabilizing mom ○ BP control with labetalol and/or hydralazine ○ Deliver that baby when mom is stable
What is Placenta previa (Level 1)
Placental implantation on or close to cervical os
● May be complete, partial or marginal
S/S Placenta previa (Level 1)
Painless bright red 3rd trimester bleeding, no fetal distress
o Remember 3 Ps - 3 rd trimester P ainless P lacenta P revia
DX of Placenta previa (Level 1)
U/S, no pelvic exam
Tx Placenta previa (Level 1)
Bed rest, stabilize baby (tocolytics, steroids), delivery
What is Postpartum hemorrhage (Level 1)
Bleeding >500 cc after vaginal delivery or >1000 cc after
c-section; Common reason for maternal death in first 24 hours after delivery
Causes of Postpartum hemorrhage (Level 1)
Uterine atony, uterine rupture, genital tract trauma, retained
placental tissues, infection
S/S Postpartum hemorrhage (Level 1)
Hypovolemic shock, soft boggy uterus with dilated cervix
tx Postpartum hemorrhage (Level 1)
Uterotonic agents (Oxytocin, Misoprostol), bimanual massage, artery embolization
Common reason for maternal death in first 24 hours after delivery
Postpartum hemorrhage
What is Premature rupture of membranes (PROM) (Level 1)
Premature (PROM): >1 hour before onset of labor
● Preterm Premature (PPROM): <37 weeks gestation
Risks of Premature rupture of membranes (PROM) (Level 1)
Smoking, STIs, multiple gestations
s/s of Premature rupture of membranes (PROM) (Level 1)
Gush or leak of fluid, vaginal discharge
DX of Premature rupture of membranes (PROM) (Level 1)
Sterile speculum exam for visual inspection
■ NO digital exam
○ Nitrazine paper test (turns blue if pH >6.5)
○ Fern test
TX of Premature rupture of membranes (PROM) (Level 1)
Depends on GA and fetal lung maturity
○ Steroids for lung maturity <34 weeks
○ If infection present or fetal distress: Abx and deliver that baby
Def of Cord Prolapse
Abnormal positioning of umbilical cord during labor → cord compression & fetal
hypoxemia (obstetrical emergency!)
Overt Cord Prolapse
Cord moves in front (ahead) of fetal presenting part & protrudes thru
cervical canal, into or out of, vagina
Occult Cord Prolapse
Cord is positioned alongside the presenting part
Presentation: Cord Prolapse
Abrupt severe, prolonged fetal bradycardia or new onset severe
variable decelerations in a labor that was previously progressing with normal
tracings
DX: Cord Prolapse
clinical; visualization or palpation of cord
Tx: Cord Prolapse
Prompt cesarean section delivery
o Temporizing measures: manually elevating the presenting part off the cord,
placing pt in Trendelenburg or knee-chest position, retrofilling bladder with
500-700 mL saline, administering tocolytic agent (eg. terbutaline
