OB/GYN Flashcards
Amenorrhea primary vs secondary definition
Primary:
*absence of menses by age 15 in the presence of secondary sex characteristics
*absence of menses by age 13 in the absence of secondary sex characteristics
Secondary:
*absence of menses for 3mo w/ previously regular cycles
*absence of menses for 6mo w/ previously irregular cycles
*pregnancy MCC of secondary amenorrhea
Amenorrhea sx
Primary
hypergonadotropic
hypogonadotropic
Kallmanns
Secondary: UPT, prolactin, TSH
*(+) UPT = pregnancy, ↑ prolactin = prolactinemia, ↑ TSH = hypothyroidism
UPT, prolactin, TSH normal 🡪 FSH/LH
Hypergonadotropic (↑ FSH/LH) 🡪 U/S
*(+) follicles = resistant ovarian syndrome
*(-) follicles = age 🡪 <40 = premature ovarian insufficiency, ≥40 = menopause
Hypogonadotropic (↓ FSH/LH) 🡪 MRI: panhypopituitarism (Sheehan, AI), apoplexy, mass
Eugonadotropic (FSH/LH normal)
*progestin challenge (+) menses = PCOS
*hysteroscopy = adhesions, ablation
Amenorrhea tx
Cabergoline/Parlodel (pituitary tumors)
Clomid for individuals desiring pregnancy
Surgery to reconstruct the uterus
Estrogen replacement in women with premature ovarian failure*
Dysfunctional Uterine Bleeding (Abnormal Uterine Bleeding) definition of Menorrhagia, Cryptomenorrhea, Metrorrhagia, Polymenorrhea, Oligomenorrhea, Menometrorrhagia, Postcoital Bleeding
Uterine bleeding of abnormal quantity, duration, or schedule
*avg. blood loss 30-80mL
Menorrhagia: bleed >7d or blood loss >80mL
Cryptomenorrhea: light flow
Metrorrhagia: bleeding between periods
Polymenorrhea: cycle <21d
Oligomenorrhea: cycle >35d
Menometrorrhagia: excessive or prolonged bleeding occurring at irregular intervals
Postcoital Bleeding: bleeding after intercourse
Dysfunctional Uterine Bleeding (Abnormal Uterine Bleeding): anovulatory:
Anovulatory (90%): the ovaries produce estrogen but no ovulation = no corpus luteum formation
*Unopposed estrogen (from no progesterone) 🡪 endometrial growth and unpredictable shedding
Dysfunctional Uterine Bleeding (Abnormal Uterine Bleeding): Luteal Phase Defect
Luteal Phase Defect: ovulation occurs but the corpus luteum does not fully develop to make sufficient progesterone for the 14 days prior to menstruation (never transitions to secretory phase)
*Tissue not favorable for implantation
*Difficulty achieving pregnancy
*Shorter than normal cycles or heavy bleeding mid-cycle
Dysfunctional Uterine Bleeding (Abnormal Uterine Bleeding) dx and tx
dx
hCG to r/o pregnancy – FIRST STEP ALWAYS (in reproductive-age women)
Labs: CBC, TSH, iron studies, PT/PTT, progesterone, prolactin, FSH
First-line imaging: transvaginal U/S
Endometrial bx – alternative for pts w/ risk factors for endometrial cancer
*unopposed estrogen therapy, tamoxifen use, menopause after age 55, PCOS
*all women >35 w/ obesity, HTN, DM
*all women ≥45
*postmenopausal bleeding
tx
Acute Hemorrhage:
*IV high-dose estrogen
*high-dose OCs
Chronic Management:
*estrogen-progestin OCPs
*tranexamic acid (clotting promoter that can treat heavy bleeding)
*IUD
*NSAIDs
*surgery – hysterectomy definitive mgmt.; endometrial ablation alt.
Ectopic Pregnancy defintion, MC location, RF
Implantation of the fertilized ovum outside the uterine cavity
Locations: fallopian tube MC
*others: abdomen, ovary & cervix
MC occur 6-8wks after LMP
Risk Factors:
*previous ectopic strongest RF
*hx of PID (one of the MC)
*IUD use
Ectopic Pregnancy sx, dx, tx
sx
Classic triad: amenorrhea followed by unilateral pelvic or lower abdominal pain + vaginal bleeding
Atypical: vague sxs, menstrual irregularities
Ruptured: severe abdominal, left shoulder pain (Kehr sign)
*dizziness, N/V
*peritonitis: guarding, rigidity, or rebound tenderness)
*signs of shock (from hemorrhage): syncope, tachycardia, hypotension
PE: adnexal mass, cervical motion tenderness, unexplained hypotension
dx
Quantitative beta-hCG: confirms pregnancy – should double every 48-72hrs; in ectopic, serial beta-hCG fails to double
Transvaginal U/S: absence of gestational sac w/ beta-hCG levels >1500 strongly suggests ectopic; adnexal mass w/ free fluid in cul-de-sac
*5.5-6wks earliest it can be detected on U/S
Serum progesterone: <5mg/mL is a nonviable pregnancy; >20ng/mL is most likely a healthy pregnancy
Laparoscopy - most accurate technique of identification of ectopic pregnancy (not often used)
tx
Methotrexate: destroys trophoblastic tissue
*indications: hemodynamically stable pts w/ early gestation (<4cm, hCG <5000, no fetal heart tones) who will be compliant w/ follow up & are immunocompetent
*contraindications: ruptured, abnormalities in hematologic, renal, or hepatic lab values, immunodeficiency, pulm. diseases such as TB, peptic ulcer disease, breastfeeding
*RhoGAM given to Rh (-) women!!!
Surgical: laparoscopic salpingostomy or salpingectomy
*mainly reserved for pts w/ contraindications to MTX or if ruptured (unstable, >3-4cm, hCG >5000)
Follow up: serial beta-hCG to see if there is a 15% decrease in 4-7 days – followed until it returns to 0
Endometriosis defintion, locations, RF
Implantation of endometrial tissue (stroma & glands) outside the uterus
Locations:
*ovaries MC site
*posterior cul de sac, broad & uterosacral ligaments, rectosigmoid colon, bladder
Risk Factors:
*prolonged estrogen exposure (e.g., nulliparity, late first pregnancy, early menarche, short menstrual cycles)
*family hx, heavy menstruation
*peak incidence 25-35yrs
Endometriosis sx
sx
Appearance:
*small (1mm) clear or white lesions
*small, dark red (“mulberry”) or brown (“powder burn”) lesions
*cysts filled w/ dark red or brown hemosiderin-laden deposits (“chocolate cysts”)
*dark red or blue “domes” that may reach up to 20mm
Classic Triad: dyschezia + dysmenorrhea + dyspareunia
*abnormal bleeding
*+/- back pain, pre or post menstrual spotting
*asymptomatic in 1/3
*infertility
PE: may have fixed tender adnexal mass, a fixed retroverted uterus or nodular thickening of the uterosacral ligament
*”classic” sign of uterosacral nodularity
*tenderness in posterior vaginal fornix
Endometriosis dx and tx
dx
U/S – initial imaging of choice to r/o other causes
Laparoscopy w/ bx – definitive dx
*raised, patches of thickened, discolored scarred or “powder burn” appearing implants of tissue
*endometrioma – endometriosis involving the ovaries large enough to be considered a tumor, usually filled w/ old blood appearing chocolate-colored (“chocolate cyst”)
dx
Medical Management:
*ovulation suppression – combined OCPs first line
*NSAIDs for pain
*progestins (levonorgestrel-releasing IUD)
*leuprolide (GnRH agonist)
*danazol (an androgen not commonly used)
Surgical Management:
*conservative laparoscopy w/ ablation of ectopic endometrial tissue used if fertility desired (preserves uterus & ovaries)
*total abdominal hysterectomy & bilateral salpingo-oophorectomy if no desire for fertility
ENDOMETRIOMA defintion, sx, dx, tx
ENDOMETRIOMA – adnexal mass that consists of ectopic endometrial tissue in pts w/ endometriosis
S/SXS: dysmenorrhea, dyspareunia, & abdominal pain that is not localized to the uterus during menses
PE: palpable adnexal mass & discomfort on palpation
Transvaginal U/S – smooth walled w/ homogenous internal echoes w/ ground-glass appearance
BX – chocolate-colored
TX: observation w/ serial U/S or surgical removal
*surgical removal: definitive dx, relief of sxs, protection against possible ovarian torsion or rupture
-Risks: intraoperative complications (hemorrhage, infection), slightly decreases fertility
Fetal Distress: FHR baseline, indications of Brady/tachycardia
Monitoring: used to determine if a fetus is well-oxygenated *electronic (EFM) MC method
*Goal is to detect signs of fetal jeopardy in time to intervene before irreversible damage occurs
Baseline FHR: mean bpm (rounded to 0 or 5) over a 10min interval, must be identifiable for 2min during the interval (but not necessarily contiguous 2min)
*110-160bpm = NORMAL
*<110bpm = bradycardia
*>160bpm = tachycardia
Bradycardia: maternal BB therapy, hypothermia, hypoglycemia, hypothyroidism, fetal heart block, interruption of fetal oxygenation
*baseline <80bpm 🡪 non-reassuring fetal status
Tachycardia: chorioamnionitis MCC, maternal fever, infections, medications, hyperthyroidism, elevated catecholamines, fetal anemia, arrhythmia, interruption of fetal oxygenation
*non-reassuring fetal status = tachycardia associated w/ ↓ variability, repetitive late or severe variable decelerations
FHR pattern: variability
VARIABILITY: fluctuations in baseline FHR that are irregular in amplitude & frequency measured in a 10min window
*absent = amplitude undetectable, minimal = 0-5bpm, moderate = 6-25bpm, marked = >25bpm
Moderate FHR variability is a reassuring sign that reflects adequate fetal oxygenation & normal brain function
*in the presence of normal FHR variability, regardless of any other FHR patterns, the fetus is not experiencing cerebral tissue asphyxia
↓ variability: associated w/ fetal hypoxia, acidemia, drugs that may depress the fetal CNS (maternal narcotic analgesia, should recover as medication wears off after D/C), fetal tachycardia, fetal CNS & cardiac anomalies, prolonged uterine contractions, prematurity, & fetal sleep (if due to fetal sleep, should recover in 20-60min)
FHR pattern: deccelerations
DECELERATIONS: ↓ in FHR from baseline (nadir = lowest point)
Early Decelerations: mirror contractions in timing & shape, not associated w/ fetal hypoxia or acidemia, benign
Late Decelerations: nadir after peak of contraction; gradual*
*most often a reflex fetal response to transient hypoxemia during a contraction, non-concerning if there is +baseline variability or accelerations
recurrent late decelerations w/ absent/minimal variability & NO accelerations can be a sign of uteroplacental insufficiency 🡪 severe hypoxemia & metabolic acidemia
Variable Decelerations: abrupt decline & return to baseline that vary in timing w/ contraction, only cause for concern if repetitive/severe (<60bpm)
Prolonged Deceleration: ↓ in FHR ≥15bpm lasting ≥2min but <10min, same causes as late/variable decelerations
*prolonged deceleration ≥10min considered change in baseline
FHR patterns: accelerations
ACCELERATIONS: ABRUPT ↑ in FHR, frequently associated w/ fetal movement, +accelerations indicate absence of hypoxia & acidemia
*<32wks: peak ≥10bpm above baseline for ≥10s
*≥32wks: peak ≥15bpm above baseline for ≥15s
FHR patterns: sinusoidal
SINUSOIDAL PATTERN: smooth, sine wave-like undulating pattern in FHR baseline w/ a cycle frequency of 3-5/min of regular amplitude of 5-15bpm that persists ≥20min, associated w/ fetal anemia, rare
FHR: category 1-3
Category I: intermittent or continuous fetal monitoring based on clinical status & underlying risk factors, review q30min in first stage of labor & q15min in second stage
Category II/III: prepare for delivery
*reposition mom in left lateral decubitus, administer IVF bolus
*D/C any uterotonic drugs to ↓ uterine contraction
*scalp stimulation to provoke FHR acceleration
(+)acceleration: fetus not acidotic
*no improvement after conservative measures + scalp stimulation does not result in acceleration 🡪 delivery advised
Intrauterine Pregnancy vaginal/cervical changes (Chadwick, goodells, ladin, haegars sign), amenorrhea, breast changes, skin changes
Vaginal/Cervical Changes
*Chadwick: mucosa appears dark bluish red & congested
*Goodells sign: cervical softening
*cervical mucus: thick due to P
*uterine change:
*Haegers sign: isthmus soften (6-8)
*Ladin sign: uterus softens (6wk)
Amenorrhea
*cessation of menses in a health
*not reliable until 10d + after menses
*can have “implantation bleeding” for blastocyst
Breast Changes
*tenderness & paresthesia
*increase in breast & nipple
*thick yellowish fluid 🡪 colostrum
*areola becomes deeply pigmented
Skin Changes ~16th wk
*increased pigmentation, linea nigra
*pruritic papules 🡪 steroids
*chloasma 🡪 “mask”
*striae (stretch marks)
Fetal Movement 16-20 weeks
*Primigravida ~20wk
*Multigravida ~16-18wk
Heart Tones: 10-12 weeks
Intrauterine Pregnancy dx
*urine beta-hCG – can detect pregnancy 14d after conception
*serum beta-hCG – can detect pregnancy as early as 5d after conception
Transvaginal U/S structures during the 1st TM
*gestational sac – can be seen at 4.5-5wks
*yolk sac – can be seen at 5-6wks; first structure to appear within gestational sac & confirms intrauterine pregnancy
*fetal pole w/ cardiac activity – around 5.5-6wks
Estimated Due Date:
*Naegele’s Rule
-LMP + 9mo + 7d
-assumes pregnancy begun
2wk before ovulation
*Ultrasound
1st trimester crown rump is MOST ACCURATE
Intrauterine Pregnancy tx
Nulligravida: currently not pregnant, never been pregnant
Primigravida: currently pregnant, never been pregnant before (aka first pregnancy)
Multigravida: currently pregnant, has been pregnant before (aka ≥2nd pregnancy)
Nullipara: never completed a pregnancy beyond 20wks
Primipara: given birth 1 time after 20wks
Multipara: ≥2 births after 20wks
G&P (TPAL)
G – number of pregnancies
P – number of actual deliveries
*T – term (>37wks)
*P – preterm (>20wks, <37wks)
*A – abortions/miscarriages (<20wks)
*L – living children
Breast Abscess defintion, sx, dx, tx
Localized collection of pus in breast tissue
Rare complication of acute mastitis
*smoking significantly associated w/ recurrence
MC in lactating women secondary to nipple trauma (esp. primigravida)
Etiology: Staph aureus MC
*Others: streptococcus, candida albicans
sx
*unilateral breast pain (esp. one quadrant) w/ tenderness, warmth, swelling, fever
*cracked nipples or visible fissure + induration and fluctuance (due to pus)
*may have purulent nipple discharge
dx
Clinical based on PE
U/S – if question of cellulitis vs. abscess; ill-defined mass w/ septations if abscess
Aspirated fluid cultures – staph aureus presents as gram + cocci in clusters
tx
Drainage via needle aspiration (lactational abscess) or I&D + abx
*nafcillin/oxacillin + metronidazole
*MRSA 🡪 TMP-SMX or clindamycin
*not a contraindication to breast feeding – milk drainage is important to facilitate resolution of infection
Mastitis defintion, sx, dx, tx
Infection of the breast MC in lactating women secondary to nipple trauma (esp. primigravida in the first 6wks postpartum)
RF: age >30yrs, gestational age ≥41wks, 1st pregnancy, tobacco use
Etiologies: staph aureus MC
*Others: streptococcus, candida albicans
sx
*unilateral localized breast pain, tenderness, warmth, swelling, induration, & skin redness
*cracked nipples or visible fissure
*+/- purulent nipple discharge
*systemic sxs: fever, myalgias, chills
Congestive: bilateral
Infectious: unilateral
dx: Clinical
Culture of breast milk – for sensitivities
Imaging – reserved for cases not responding to empiric abx within 48-72hrs
tx
Supportive: warm/cool compresses, breast pump, anti-inflammatory medications
Abx: dicloxacillin, cephalexin, erythromycin
*erythromycin can be used in PCN allergy
*fluconazole if fungal
*Mothers encouraged to continue breastfeeding – milk drainage is critical for resolution of infection & relief of sxs
Ovarian Cysts: follicular, corpus luteal, theca lutein defintion
Fluid-filled sac within the ovaries MC related to ovulation (usually unilateral)
Common in reproductive years – most spontaneously resolve within a few weeks
Follicular Cysts: MC – occur when follicles fail to rupture & continue to grow
*Lengthening of follicular phase - transient secondary amenorrhea
*Does not become clinically significant until it is large enough to cause pain or persists beyond one menstrual cycle
Corpus Luteal Cysts: fail to degenerate after ovulation
*composed of granulosa cells
Theca Lutein: excess beta-hCG causes hyperplasia of theca interna cells (rare)
*seen in hydatidiform mole, hCG & clomid use
Ovarian Cysts: follicular, corpus luteal, theca lutein sx, dx, tx
Most are asymptomatic – may be associated w/ abnormal uterine bleeding or dyspareunia
PE: unilateral pelvic pain or tenderness, mobile palpable cystic adnexal mass
Follicular: mild to moderate lower abdominal pain & alteration in menstrual intervals
Corpus Luteal: asymptomatic, pain & local tenderness, ovarian torsion or rupture & bleeding
Theca Lutein: usually bilateral, pelvic heaviness
dx
Transvaginal U/S
*Follicular: smooth, thin-walled uniocular
*Corpus Luteal: complex, thicker-walled w/ peripheral vascularity
Malignancy:
*Low risk: anechoic, uniocular fluid-filled cysts
*High risk: solid, nodular, thick septations
If suspicious 🡪 tumor markers (CA-125, alpha-fetoprotein, beta-hCG)
Beta-hCG to r/o pregnancy
tx
If <8cm: supportive – rest, NSAIDs, repeat U/S after 1-2 cycles
*most cysts <8cm are functional & usually spontaneously resolve
*OCPs may prevent recurrence but don’t treat existing ones
If >8cm or persistent: laparoscopy or laparotomy
Postmenopausal: laparoscopy or laparotomy if large or CA-125 is elevated
*cysts in postmenopausal women are considered to be malignant until proven otherwise
Ruptured Physiologic Ovarian Cyst definition, sx, dx, tx
Asymptomatic or sudden onset of unilateral lower abdominal pain often sharp & focal, often occurring during sexual activity or strenuous physical activity
sx
Abnormal uterine bleeding
PE:
*unilateral pelvic pain or tenderness
*+/- mobile palpable cystic adnexal mass
*may have signs of hemodynamic compromise if massive bleeding (uncommon)
dx
Transvaginal U/S – initial TOC
*adnexal mass + pelvic fluid
Beta-hCG
CBC
tx
Uncomplicated: expectant management for most – observation, analgesics, rest
*uncomplicated means absence of hemodynamic instability, large volume or ongoing blood loss, fever, leukocytosis, or suspicion of malignancy
Stable + significant hemoperitoneum: hospitalization, close observation, fluid replacement
Hemodynamically unstable or ongoing hemorrhage: laparoscopy usually preferred over laparotomy; cystectomy preferred over oophorectomy
Pelvic Inflammatory Disease definition, sx, dx, tx
Ascending infection of the upper reproductive tract
Pelvic or lower abdominal pain, dysuria, dyspareunia, vaginal discharge or bleeding, N/V
PE:
*lower abdominal tenderness
*fever
*purulent cervical discharge
*cervical motion tenderness (Chandelier sign)
Tubo-Ovarian Abscess: acute lower abdominal pain, vaginal discharge, systemic sxs (fever, chills)
*PE: unilateral adnexal tenderness
*Ruptured: acute abdomen (guarding, rebound) + sepsis
Fitz Hugh-Curtis Syndrome: inflammation of the liver capsule w/ adhesion formation resulting in RUQ pain (perihepatitis)
*seen in 10% of women w/ PID
S/SXS: RUQ pain due to perihepatitis (liver capsule involvement); may radiate to right shoulder
DX: laparoscopy: “violin-string” adhesions on anterior liver surface; often have normal LFTs or slight elevations
DX: presumptive diagnosis made in any sexually active woman presenting w/ pelvic or lower abdominal pain + have evidence of cervical motion, uterine, or adnexal tenderness on exam
*this is sufficient for tx d/t serious sequelae if tx delayed/not given
Other supportive findings:
*temp >101oF (>38.3oC)
*abnormal cervical or vaginal mucopurulent discharge or cervical friability
*presence of abundant numbers of WBCs on saline microscopy of vaginal secretions (>15-20 WBCs/high power field or more WBCs than epithelial cells)
*documentation of cervical infection w/ N. gonorrhea, C. trachomatis, or M. genitalium
Workup: UPT (r/o ectopic pregnancy), NAAT (for G/C & M. genitalium), microscopy of vaginal discharge, HIV screening, RPR/VDRL
Imaging (if needed): U/S preferred
tx
Inpatient:
INITIAL:
*ceftriaxone 1g IV q24h PLUS
*doxycycline 100mg PO q12h PLUS
*metronidazole 500mg PO or IV q12h
PO after 24-48h of sustained clinical improvement:
*doxycycline 100mg BID PLUS
*metronidazole 500mg BID x14d total
Outpatient:
*ceftriaxone IM x1 PLUS
<150mg: 500mg
≥150mg: 1g
*doxycycline 100mg BID PLUS
*metronidazole 500mg BID x14d total
Pregnant: inpatient tx indicated
*substitute doxycycline w/ azithromycin
Tubo-Ovarian Abscess definition, sx, dx, tx
Inflammatory mass involving the fallopian tubes, ovaries, & occasionally other pelvic organs
*Most occur as a complication of PID
MC in ages 15-25
sx
*Pt will have hx of PID
Classic presentation: acute lower abdominal pain, vaginal discharge, & systemic sxs (fever, chills)
PE: unilateral adnexal tenderness
Ruptured: leaking contents into the abdominal cavity – pts present w/ an acute abdomen (guarding & rebound tenderness) & sepsis
*requires immediate surgical exploration
dx
Transvaginal U/S – inflammatory adnexal mass
tx
ADMIT for IV abx
*(cefoxitin or cefotetan) + doxycycline
*abx alone are sufficient for pts that are hemodynamically stable, lack signs of an acute abdomen, & are premenopausal
Dysmenorrhea primary vs secondary: definition, sx, dx, tx
Painful menstruation
Primary: ↑ prostaglandins
RF: menarche before 12yo, nulliparity, smoking, family hx, obesity
Secondary: pelvis/uterus pathology (endometriosis, PID, adenomyosis, leiomyomas)
*pain severity will progressively worsen
sx
Recurrent, crampy midline lower abdominal pain or pelvic pain 1-2 days before or at the onset of menses gradually diminishing over 12-72hrs
*may be associated w/ HA, N/V/D
PE: will be normal if primary
dx
H&P, UPT, pelvic U/S
*Laparoscopy if secondary causes are suspected
tx
Supportive therapy: heat, vitamin B & E, exercise
NSAIDs or estrogen-progestin OCPs are first line
*Laparoscopy indicated if unresponsive to 3 cycles of initial therapy to r/o secondary causes
Secondary: treat underlying cause
Placenta Abruption defintion
Partial or complete premature separation of the placenta from the uterine wall (prior to delivery of the fetus)
The blood may be concealed (within the uterine cavity) or external (blood drains through the cervix)
Patho:
*rupture of maternal blood vessels in the decidua basalis, leading to bleeding into the separated space
*the subsequent release of tissue factor, thrombin generation lead to the other findings
Risk Factors: prior abruption most significant RF
*maternal HTN MC (e.g., chronic, preeclampsia, eclampsia)
*smoking, alcohol use, cocaine, folate deficiency, advanced maternal age, abdominal trauma, multiple gestation, PPROM, chorioamnionitis
*trauma – all pts involved in MVA, fall, or traumatic event should be evaluated
*more common in AA
Placenta Abruption sx, sx, tx
Sudden onset of PAINFUL 3rd TM vaginal bleeding (often dark red), severe abdominal pain (uterine contractions)
*may have black pain or signs of shock from blood loss
*premature delivery may occur
PE:
*tender rigid (hypertonic) uterus
*fetal distress may occur (e.g., fetal bradycardia)
DO NOT PERFORM A PELVIC EXAM!!
dx
Primarily a clinical dx
Transabdominal U/S – may show a retroplacental clot (but not reliable); may be helpful to distinguish between abruptio & previa
Workup: CBC, blood type & cross, fibrinogen level
tx
Delivery – often by c-section but vaginal delivery possible & may often follow rapid labor
Complications: abruption is the MCC of coagulopathy in pregnancy – DIC, fetal death
Couvelaire uterus: blood penetrates the uterus to such an extent that the serosa becomes blue/purple
*Kleihauer-Betke test is essential to determine the amount of fetal-maternal hemorrhage; Rh D immunoglobulin given to Rh (-) mother
Placenta Previa defintion, sx, dx, tx
Abnormal placenta placement over or close to the internal cervical os
Types:
*complete: complete coverage of the cervical os
*partial: partial coverage of the cervical os
*marginal: adjacent to the internal os (leading edge of the placenta is <2cm from the internal os)
Risk Factors:
*major: previous placenta previa, previous c-section, multiple gestations
*increasing age & previous uterine surgery
*smoking
sx
Sudden onset of PAINLESS vaginal bleeding in the 3rd TM (may be bright red) usually after 28wks
*absence of abdominal pain or uterine tenderness
PE:
*soft, nontender uterus
DO NOT PERFORM DIGITAL VAGINAL/SPECULUM EXAM – may cause increased separation, resulting in severe hemorrhage
dx
Transabdominal U/S initially followed by transvaginal U/S for confirmation
tx
Stabilization w/ premature fetus: watchful waiting if the pt is stable; pelvic rest (no vaginal intercourse)
Delivery when stable: if L:S ratio > 2:1, >36wks, blood loss >500mL, coagulation defects, or persistent labor
*c-section usually preferred in complete, major degrees, & w/ fetal distress
Placenta Accreta definition
Placenta Accreta: invasion of placental tissue into the uterus prevents placenta from separating from uterine wall leading to hemorrhage – tx is hysterectomy
Vasa Previa definition, sx, dx, tx
Fetal vessels are present over the cervical os—fetal mortality approached 60% if not discovered before delivery due to fetal exsanguination
S/SXS: ROM followed by PAINLESS vaginal bleeding + fetal distress (bradycardia)
DX: may be seen prior to delivery as the vessels crossing the os
TX: immediate c-section
Premature Rupture of Membranes (PROM) deifntion, sx, dx
Rupture of the amniotic membranes before the onset of labor
If it occurs prior to 37wks 🡪 preterm premature rupture of membranes (PPROM)
sx
Gush of fluid or persistent leakage of fluid from the vagina or vaginal discharge
dx
Sterile speculum exam: pooling of secretions in posterior fornix w/ inspection
Nitrazine paper test: turns blue if pH >6.5 (amniotic fluid pH is ~7 whereas vaginal pH usually ~4)
Fern test: amniotic fluid dries in a fern pattern (crystallization of estrogen & amniotic fluid)
U/S to check amniotic fluid index
*avoid digital vaginal examination unless delivery is imminent (to avoid introduction of infection)
PROM vs PPROM tx
Complications: may lead to chorioamnionitis or endometritis if prolonged (>24h)
*cord prolapse, placental abruption
PROM:
*Expectant: admit w/ fetal monitoring & wait for spontaneous labor (90% will go into labor within 24hrs after PROM) – monitor for infection (chorioamnionitis or endometritis)
*Labor induction: if chorioamnionitis or labor does not occur within 18hrs of rupture
-prostaglandin cervical gel or oxytocin
PPROM:
≥34wks, no sign of maternal or fetal infection or distress: admit w/ fetal monitoring & wait for labor
<34wks: administer steroids (betamethasone) to enhance fetal lung maturity
*if 24-32wks 🡪 admin magnesium sulfate (neuroprotection)
*tocolytics may be given to delay delivery 48hrs to allow steroids to work if not in advanced labor (>4cm), no signs of chorioamnionitis, & no signs of non-reassuring fetal testing
*abx (ampicillin + erythromycin) often given to prevent infection
*Prompt delivery if signs of maternal or fetal infection or distress
Abortion definition, sx, dx
A pregnancy that ends before 20wks gestation – almost 80% occur before 12wks
sx
Crampy abdominal pain & vaginal bleeding
Recurrent SAB: ≥3 consecutive losses <20wks GA (15% risk in 1st pregnancy)
*↑ risk w/ each pregnancy loss
dx
*U/S
*CBC
*blood type & Rh screen
*serial beta-hCG titers
*progesterone levels
Abortion: threatened, inevitable, incomplete, complete, missed, septic findings and tx
Threatened
dx: *products of conception (POC) intact
*cervical os CLOSED
tx: *supportive observation at home, bed rest, & close follow up to see if sxs either resolve or progress to abortion
*serial beta-hCG to see if doubling to see if viable
Inevitable
dx: *POC intact
*cervical os OPEN
tx: *surgical evacuation: D&C if <16wks; dilation & evacuation if ≥16wks
*medical: misoprostol
*expectant management
Incomplete
dx: *some POC expelled from uterus
*cervical os OPEN
tx: Options include:
*expectant: allow POC to fully pass w/ serial beta-hCG & transvaginal U/S to determine when complete
*surgical evacuation: D&C <16wks; D&E ≥16wks
*medical: misoprostol
Complete
dx: *all POC expelled from uterus
*cervical os usually closed
tx: *RhoGAM if indicated, follow up beta-hCG
Missed
dx: *POC intact
*cervical os CLOSED
*no bleeding or cramping
tx: *surgical evacuation: D&C <16wks; D&E ≥16wks
*medical: misoprostol
Septic
dx: *some POC retained
*cervical os CLOSED – cervical motion tenderness
*foul brown discharge, fever, chills
tx: *D&E to remove POC + broad spectrum abx (levofloxacin + metronidazole)
Gonorrhea sx, dx, tx
Neisseria gonorrhea
*most women are asymptomatic
S/SXS: mucopurulent discharge, vulvar itching/burning
*be sure to think of gonococcal pharyngitis in anyone w/ persistent pharyngitis, dx w/ culture
dx
Nucleic acid amplification test
Gram stain: gram (-) diplococci
tx
<150kg: ceftriaxone 500mg IM x1
≥150kg: ceftriaxone 1g IM x1
Alt: cefixime (400mg PO)
*MC complication is salpingitis
Chlamydia sx, dx, tx
*MC reported STI in US
S/SXS: mucopurulent discharge, hypertrophic cervical inflammation
dx
Nucleic acid amplification test
Culture
UA – will reveal pyuria w/ no organisms on gram stain
tx
Doxycycline 100mg BID x7d
Alt: Azithromycin 1g PO x1 (preferred in pregnancy)
Trichomoniasis sx, dx, tx
Trichomonas vaginalis: flagellated protozoan
sx
*Purulent, malodorous, thin vaginal discharge – green/yellow, frothy <10%
*Burning, pruritus, dysuria, frequency and dyspareunia
*Postcoital bleeding
*30% of women can be asymptomatic
PE: erythematous vulva and vaginal walls (mucosa), thin (snot like) discharge
*Strawberry (punctuated) cervix (<2%)
dx
Wet prep – mobile flagellated organism (trichomonads) & many leukocytes
tx
Metronidazole (2g once or 500mg BID x7d)
OR
Tinidazole (2g once)
*Avoid ETOH on metronidazole – disulfiram rxn
Bacterial Vaginosis defintion, sx, dx, tx
An overgrowth of anaerobic bacteria, which replaces the normal lactobacilli of the vagina, increased pH allows for growth of Gardnerella vaginalis
sx
*Vaginal discharge – white homogenous consistency
*Fishy odor – exacerbated by menses, intercourse, or douching (introduction of alkaline substances)
PE:
*Vaginal discharge – “spilled milk over the tissue”, homogenous thin white discharge that coats the vaginal walls
*No erythema or inflammation of vaginal mucosa
dx
Wet mount – CLUE CELLS (bacterial coated epithelial cells); NO LEUKOCYTES
Vaginal fluid pH >4.5 (elevated)
Whiff test: addition of KOH leads to release of a fishy odor
Gram stain – gold standard
tx
Metronidazole PO or topical
*500mg BID x7d
*250mg TID x7d
Clindamycin topical
Atrophic Vaginitis defintion, sx, dx, tx
Atrophy of the vaginal epithelium due to diminished estrogen levels
sx
*vaginal dryness, dyspareunia
*vaginal inflammation
*infection & recurrent UTIs w/ increased pH (loss of lactobacilli which normally converts glucose to lactic acid)
dx: clinical
tx
Vaginal moisturizers – improves sxs of dyspareunia & dryness but no effect on atrophy
Topical vaginal estrogens – safest, most effective medical therapy – cream, vaginal ring, vaginal troches
ADRs: vaginal bleeding, breast pain, nausea, thromboembolism (DVT, CVA, PE), endometrial cancer (less risk compared to oral estrogen)
Ospemifene – SERM; estrogen agonist in vagina/bone, estrogen antagonist in breast/uterus
Candidiasis definition, sx, dx, tx
90% from Candida albicans
sx
*Vulvar itching, burning, dysuria, dyspareunia
*Vaginal discharge
PE:
*Erythematous vulvar and vaginal tissue
*Thick, adherent “cottage cheese” discharge, no odor
dx
KOH prep on microscopy: PSEUDOHYPHAE
tx
Topical or intravaginal miconazole (monistat), clotrimazole, terconazole
Fluconazole 150mg PO
*Recurrences are common; if frequent, work up diabetes/autoimmune disease
Gestational Trophoblastic Disease (Molar Pregnancy) definition, sx, dx, tx
Neoplasm due to abnormal placental development w/ trophoblastic tissue proliferation arising from gestational tissue (not maternal in origin) – 80% benign
Abnormal proliferation of the syncytiotrophoblast and replacement of normal placental trophoblastic tissue by hydropic placental villi
sx
Painless vaginal bleeding, preeclampsia (HTN) BEFORE 20wks, hyperemesis gravidarum (due to elevated beta-hCG levels)
*tachycardia, weight loss (d/t hyperthyroidism)
PE: uterine size & date discrepancies (larger or smaller than expected)
dx
Beta-hCG: markedly elevated w/ complete (e.g., >100,000mIU/mL)
Pelvic U/S
*complete: central heterogenous mass w/ multiple discrete anechoic spaces “snowstorm” or “cluster of grapes” appearance, absence of fetal pole & heart tones
*partial: gestational sac & fetal heart tones may be present plus abnormal tissue
tx
Surgical uterine evacuation mainstay of tx ASAP to avoid risk of choriocarcinoma development
*Pts are followed weekly until beta-hCG levels fall to an undetectable level
Choriocarcinoma definition, sx, dx, tx
*Malignant transformation of trophoblastic tissue
*Tumor has a red, granular appearance on cut section and consists of intermingled syncytiotrophoblastic and cytotrophoblastic elements with many abnormal cellular forms
*Characterized by rapid myometrial and uterine vessel invasion and systemic metastases resulting from hematogenous embolization – lung, vagina, CNS, kidney, liver
*May follow molar pregnancy, normal term pregnancy, abortion or ectopic
*Abnormal bleeding for 6wks after any pregnancy should be evaluated w/ hCG to exclude new pregnancy or GTN
-Failure to regress after treatment of molar pregnancy suggests further treatment is needed
Treatment:
*Usually highly sensitive to chemotherapy, allowing a cure/future fertility
*Nonmetastatic persistent GTN - single dose MTX
*Use FIGO score for staging
Preeclampsia defintion and patho
New onset of HTN (>140/90mmHg) occurring after 20wks gestation + proteinuria or end-organ dysfunction in a previously normotensive female
*BP measurements done on at least 2 occasions at least 4hrs apart
Risk Factors: preexisting HTN, nulliparity, maternal age <20yrs or >35yrs, diabetes, chronic renal disease, autoimmune disorders
patho
*As the placenta integrates into the endometrial layer, there is defective remodeling of the spiral arteries
*Pt develops placental hypo-perfusion; that releases proinflammatory proteins into maternal circulation, which cause vasoconstriction of maternal vascular system and end-organ damage
*Damage of endothelial cells potentiates the release of inflammatory cytokines
Preeclampsia severe vs non severe sx and dx
Pre-Eclampsia w/o Severe Features
BP ≥140/90 *≥2 occasions ≥4h apart
PLUS
Proteinuria: ≥300mg 24h OR protein:Cr >0.3
Pre-Eclampsia w/ Severe Features
*any ONE of the following
BP ≥160/110
Platelets <100,000
SCr >1.1mg/dL or 2x baseline
ALT/AST 2x normal or persistent epigastric/RUQ pain
Pulmonary edema
Cerebral/visual changes (HA, blurred vision, flashing lights)
Preeclampsia tx mild vs severe
MILD: anti-HTN meds NOT recommended
≥37wks: delivery
<37wks: expectant management w/ delivery @37wks
*daily weights, weekly BP & dipstick, bed rest
* antenatal corticosteroids to mature lungs if <34wks
SEVERE: delivery is only cure!!!!
≥34wks: delivery
*magnesium sulfate (D/C ≥24hrs after delivery)
*BP control (labetalol, hydralazine, nifedipine)
<34wks: steroids for fetal lung maturity
*delivery at 34wks if well-controlled w/ anti-HTN
*sxs/not controlled w/ anti-HTN meds 🡪 delivery
Preeclampsia indications for delivery
MATERNAL INDICATIONS:
*Recurrent severe HTN
*Recurrent severe symptoms of pre-E
*Progressive renal insufficiency
*Persistent thrombocytopenia
*Pulmonary edema
*Suspected placental abruption
*Progressive labor or ROM
FETAL INDICATIONS:
*Gestational age >34wks
*Severe fetal growth restriction (<5%)
*Persistent oligohydramnios
*BPP of 4/10 or less on two occasions 6 hours apart
*Reversed end-diastolic flow on umbilical artery Doppler
*Recurrent variable or late decelerations during NST
*Fetal demise
Preeclampsia anti-hypertensive therapy
WARNING: In patients with pre-E WITHOUT severe features, anti-HTN therapy may ↓ risk to pre-E w/ severe features, however it can also impair fetal growth by ↓ blood flow to the fetoplacental unit
*For women w/ chronic HTN, it is recommended to initiate anti-HTN therapy when BP reaches >160/105
*Do not withhold therapy in women w/ severe features that do not meet “number criteria” if there are signs of end-organ damage
ACUTE IV/IM AGENTS
Labetalol: FIRST LINE; contraindicated in pts that cannot tolerate non-selective BBs (asthma)
Hydralazine: higher or frequent dosage is associated w/ maternal hypotension, HA, & fetal distress (may be MC than w/ other agents)
Nifedipine: may observe reflex tachycardia & HA
CHRONIC PO AGENTS
Labetalol: well-tolerated, potential bronchoconstriction
Nifedipine: do NOT use sublingual forms
Methyldopa: may not be as effective in control of severe HTN but multiple safety studies
Thiazide diuretics: second line agent
ACEI/ARB: CONTRAINDICATED (associated w/ fetal anomalies)
HELLP syndrome defintion, sx, dx, tx
*Severe preeclampsia can also present w/ HELLP syndrome
H: hemolysis
EL: elevated liver enzymes
LP: low platelet count
tx
Delivery:
≥37wks: delivery after maternal stabilization
<37wks: delivery after stabilization if mother has any of the following:
*DIC
*Liver infarct or hemorrhage
*Renal failure
*Pulmonary edema
*Placental abruption
*Non-reassuring fetal status
Eclampsia defintion, sx, dx, tx
Preeclampsia + seizures or coma
sx
Signs of Impending Eclampsia:
*HA +/- blurred vision
*photophobia
*epigastric/RUQ pain
*altered mental status
Abrupt onset of tonic-clonic seizures
tx
MEDICAL EMERGENCY!!!!
ABCD – airway, breathing, circulation, delivery (c-section MC)
IV magnesium sulfate for seizures & BP stabilization (IV labetalol or hydralazine) followed by delivery of the fetus (once the mother is stabilized)
*lorazepam only used if seizures are refractory to magnesium sulfate
IV magnesium sulfate
*loading dose of 4-6g followed by maintenance of 1-2g/hr for ≥24h
Magnesium sulfate – therapeutic levels: 4.8-8.4mg/dL
*can monitor for toxicity w/ patellar reflexes
Endometritis definition, sx, dx, tx
Infection of the decidua (pregnancy endometrium)
*MC postpartum infection
Usually polymicrobial (often vaginal flora, aerobic, & anaerobic bacteria)
*group A & B streptococci, staph, klebsiella, proteus, Enterobacter, enterococcus, E. coli
Risk Factors:
*C-SECTION BIGGEST RISK FACTOR
sx
Fever, uterine tenderness, tachycardia that parallels rise in temp, midline lower abdominal pain
May have vaginal bleeding or discharge (foul-smelling lochia)
*diminished or absent bowel sounds is a sign of a more serious infection
ALARM FINDINGS:
Fever ≥103F
OR
Fever ≥102F plus
*HR ≥110 for at least 30min
*RR ≥20 for at least 30min
*manual WBC w/ 10% bands
*BP ≤90/60
dx
Mainly a clinical dx – fever (≥100.4F), tachycardia, abdominal pain, uterine tenderness 2-3d after c-section, postpartum, or postabortal
WBC 15,000-30,000 w/ left shift (leukocytosis)
Elevated LDH
tx
Clindamycin + gentamicin
If GBS: ADD ampicillin or Augmentin
