Ob-Gyn Flashcards
woman with breast mass
<30
1) US
- simple breast cyst (can be quite painful) - posterior acoustic enhancement (fluid), no echogenic debris… –> cystic fluid can reaccumulate so pt should f/u in 2-4 mo for repeat clinical breast examination –> no recurrence or sx –> annual screening
MRI - cancer
- and use it for women with increased risk of cancer (BRCA and their relatives, genetic syndrome, hx of radiation during ages 10-30
diagnostic mammography - DONT in women < 30 (dense breast tissue prevents visualization), radiation risk
- diagnostic to evaluate risk
needle aspiration for breast mass
core bx if suspicious imaging (mammogram) - for complex cysts, masses, or recurring mass
when would you image - unilateral breast discharge, bloody or serous d/c, or palpable lump or skin changes
- mammo or US accordingly
- nipple discharge that looks benign - UPT, TSH, prolactin, guaiac
HCG in pregnancy
secreted by syncytiotrophoblasts - preserves corpus luteum during early pregnancy –> progesterone secretion
- eventually placenta produces progesterone(?) on its own
- HCG also promotes male sexual differentiation and stimulation of maternal thyroid gland
HCG - 8 d after fertilization, doubles every 48 hrs –> peak at 6-8 wks gestation
a-unit - common to hCG, TSH, LH, and FSH
note - prog > 25 ng/mL suggests healthy pregnancy
- prog <5 ng/ml suggests abnormal or extrauterine pregnancy
pregnancy
division of fertilized egg occurs before implantation
30% of nl pregancies experience first trimester spotting and bleeding
pregnancy in perimenopausal women - insomnia, amenorrhea, enlarged uterus, weight gain (interestingly, these overlap with the sx of menopause)
- in menopause - women will have decreased size of uterus
- get bHCG
teratogens
greatest risk of microcephaly and ID - 8-15wks gestation
albuterol, beclamesthasone not associated with birth defects
- amitrip, levo, and acyclovir are also safe
Li - Ebstein anomaly (inferior tricuspid valve, atrialization of the right ventricle), wean
Isoretinoin - associated with craniofacial dysmorphism, heart defects, deafness
- for women of repro age - need two forms of contraception for 1 mo prior to initiating treatment
- continue contraception 1 mo after med is d/c
- routine pregnancy tests
anticonvulsants - craniofacial defects, neural tube defects, genital anomalies
FQs - fetal bone deformities and arthropathy
TMP-sulfa - contraindicated in first trimester due to interference with folic acid metabolism, avoided in 3rd trimester due to increased risk of neonatal kernicterus
women with poorly controlled DM prior to conception –> increased risk of CNS and cardiac defects
- caudal regression syndrome (rare)
- increased risk of premie, fetal death, hypertensive complications, polyhydramnios
autosomal trisomy - most common karyotype in spontaneously aborted fetuses
endometriosis
> 6 mo
dysmenorrhea (sometimes dyschezia aka pain with defecation), dyspareunia, noncyclic pain that is exacerbated by exercise, infertility (1 year trying unsuccessfully)
- wont have heavy menstrual bleeding
physical exam - fixed immobile uterus, rectovaginal nodularity, adnexal mass (confirm with US)
pelvic US can be normal
treatment if symptomatic
- NSAIDs, OCPs (OCPs suppress ovulation, pseudopregnancy state –> may result in atrophy of endometrial tissue)
- laparoscopy after failure of empiric therapy
- leuprolide (aka medical menopause)
- danazol is a 17-a-e- testosterone derivative that suppresses the mid-cycle surges of LH and FSH
- definitive treatment with surgical resection and hysterectomy with oophrectomy
infertility is commonly the sole symptom of endometriosis
note - adenomyosis more common in women > 40
- new-onset dysmenorrhea and heavy menses that can progress to chronic pelvic pain
- enlarged, boggy, globular, and tender
- treatment is hysterectomy, can try hormonal methods prior
- side note - hyperplasia and carcinoma do not typically cause uterine enlargement
teratoma
on US - calcifications and hyperechoic nodules
well-differentiated ectodermal cells
lactation suppression
wear comfortable bra, avoid nipple stimulation/manipulation (so dont pump and dump, oxytocin and prolactin release will be stimulated), apply ice pacs, and NSAIDs
prolactin levels
- note manual stimulation during exam will increase prolactin level –> accurate levels obtained after fasting and NO breast stimulation for 24hrs
- if still elevated - get TSH and brain MRI
lactation suppression –> negative inhibition of prolactin release
meds not indicated - note bromocriptine no longer approved by FDA due to side effects
oxytocin
used to induce labor and prevent/manage PP hemorrhage
adverse effects - hyponatremia (similar to vasopressin, interestingly oxytocin can enhance ADH secretion), hypotension (used for PP hemorrhage), uteirne tachysystole (aka >5 contractions in 10 min, averaged over a 30 min period)
- usu no adverse outcomes with tachysystole - but FHR will show fetal hypoxia signs
- tachysystole –> increased risk for C-section, low umbilical cord pH, NICU admission
precipitous labor
fetal delivery w/i 3 hrs of start of contractions - usu in multips
GBS
screening - rectovaginal culture at 35-37 wks
indications (no need for screening, just give antibiotics) - many
- prior delivery complicated by GBS infeciton
- GBS bacteriuria at any point during current pregnancy
- pos culture
- unknown GBS and <37 wks, intrapartum fever, ROM for 18+ hrs
intrapartum penicillin - 4 hrs before delivery
PP hemorrhage
ob emergency - < 24hrs after delivery, most commonly due to uterine atony (boggy and enlarged, above the umbilicus on physical exam)
- risk factors - prolonged labor, precipitous labor, over-distention (multiple gestation, macrosomia…), chorioamnionitis, operative vaginal delivery (including forceps-assist), HTN, general anesthesia
- note - factors that lead to overdistended uterus are risk factors for uterine inversion (but most common cause is traction on cord) - other causes include - retained placenta, lac, uterine rupture (surgery), coagulopathy
hemostasis after placenta delivery is achieved by clotting and myometrial contraction
treat with - bimanual uterine massage and oxytocin
- fluids, O2, stabilize
- check for well-contracted uterus, no retained placental tissue, and lacs
- uterotonics - methylergonovine (causes smooth muscle contraction, contraindicated in HTN), carboprost (~PG, causes bronchoconstriction, contraindicated in asthma), misoprostol
- balloon tamponade
- B lynch suture (at time of laparotomy)
- uterine artery embolization, ligation, can also ligate hypogastric (internal iliac) artery
- hysterectomy
FHR
110-160, 6-25 mod amplitude variability
fetal tachy - maternal fever (chorio), maternal hyperthyroidism (TSH stimulating antibodies cross the placenta), meds (terbutaline), abruptio placentae
- chorio - risk factors are prolonged ROM (> 18hrs) and nulliparity
- can occur when membranes are intact
- polymicrobial infection
- ddx by maternal fever + 1 of the following: maternal tachy or fetal tachy, uterine fundal tenderness, foul-smelling amniotic fluid, purulent vaginal discharge, leukocytosis > 15K
- promptly administer antibiotics (IV amp, gent, clinda) and DELIVER
- complications include - uterine atony, PP hemorrhage, endometritis, premature birth, infection, encephalopathy, CP, death
accelerations - correspond to fetal movement, due to fetal SNS (which matures at 26-28 wks)
- in NST 2 or more accelerations = high NPV to rule out fetal acidemia
- side note - you would perform an NST for pregnancies at risk for fetal hypoxia/demise (so maternal disease, growth restriction)
- nonreactive stress test means there are no acceleration
- fetal scalp stimulation can induce accelerations
early decels - nadir lines up with contraction, gradual onset
- due to fetal head compression (–> vagal response –> slows HR)
- can be normal in tracing
late decels - after contraction, gradual onset
- uteroplacental insufficiency
- due to chronic HTN and postdate pregnancies
- sometimes due to IUGR
- initial step is to treat fetal hypoperfusion is maternal left lateral position, O2 supplementation, treatment of mat hypotension, d/c oxytocin, intrauterine resuscitation with tocolytics and IVFs
- augmentation of labor can increase the late decels
variable - abrupt (<15 from onset to nadir, sharp shape)
- due to cord compression, oligohydraminos, cord prolapse (occurs with sustained fetal brady), nuchal cord
- recurrent variables - fetal hypoxemia, 1) maternal repositioning (left lateral), 2) amnioinfusion
late and variables - risk for fetal hypoxemia and acidosis
sinusoidal tracing - fetal anemia
inactive sleep and fetal hypoglycemia - no accelerations present
- fetal sleep can last 40 min long
- high false positive rate for nonreactive NSTs (confirmation necessary) - for ex with biophysical profile (assesses fetal status)
loss of variability –> C-section
- maternal drugs may cause loss of variability
fetal HR minimally variable and no accels –> fetal scalp stimulation
- -> fetal scalp pH, vibroacoustic stimulation, or allis clamp test
- indication of fetal acid-base status
uterine hyperstimulation –> may cause prolonged bradycardia
HTN in pregnancy
measurements - 2 measurements at least 4 hrs apart
gestational HTN
preeclampsia - >140/90 at >20 wks + proteinuria or end-organ damage
- urine protein/Cr ratio or 24hrs collection for total protein
- risk factors - nulliparity and mat age < 18 and >40, chronic HTN, hx of preeclampsia, DM, and renal disease
- severe features - >160/110, thrombocytopenia < 100K, elevated Cr > 1.1, elevated LFTs, pulm edema, visual or cerebral symptoms
- wo severe features - deliver at >37 weeks
- w severe features - deliver at > 34 wks
- MgSO4 for seizure ppx, anti-HTNs
- MgSO4 tox –> arreflexia –> NM depression –> cardiac depression - consequences - chronic uteroplacental insufficiency –> fetal growth restriction, DIC in mom, abruptio placenta, hepatic rupture, eclamptic seizures
eclampsia - ….severe headaches, visual disturbances, RUQ or epigastric pain, tonic-clonic seizure
- Todd paralysis - transient unilateral weakness following tonic-clonic
- seizure can lead to posterior shoulder dislocation (adducted and internally rotated, light bulb sign)
- give Mg SO4, antihypertensive, and deliver fetus
- second choice - diazepam, phenytoin
- eclampsia - associated with maternal morbidity from abruptio placenta, DIC, cardiopulm arrest
side note - in preeclampsia/eclampsia - pts can have acute pulmonary edema
- treat with supplemental O2, fluid restriction, and diuresis (with caution)
drugs - labetalol, methyldopa, hydralazine, (nifedipine po)
- things to consider - labetalol and b-blockers will lower pulse (dont give to bradycardic pts)
- methyldopa is used to treat chronic HTN, slow onset and less potent
- second line - thiazides, clonidine
- hydralazine is used acutely
- contraindicated - ACE/ARB, aldosterone blockers, direct renin inhibitors, furosemide
- generally - avoid volume depletion in pregnant pts
note - severe HTN is defined as 160/110 for >15 min
pregnancy-related risks of HTN
- maternal - superimposed preeclampsia, PPH, gestational DM, abruptio placenta, c-section
- fetal - FGR, perinatal mortality, preterm delivery, oligo
Rh
indications for ppx in Rh- pts - at 28-32 wks (and within 72hrs after birth of Rh+ baby)
- life of Rhogam is 6wks
AND
- <72 hrs after spontaneous abortion or delivering an Rh pos baby
- antepartum hemorrhage
- ectopic pregnancy, threatened abortion, mole
- CVS, amniocentesis, abdominal trauma
- 2nd/3rd trimester bleeding
- external cephalic version
post-partum Rhogam can be given up to 72 hrs after delivery - can be administered only after baby’s blood type is known
Kleihauer-Betke test used to determine the necessary dose of rhogam
- at 28 weeks - test for sensitization with an indirect Coombs
- 30 cc blood - 300 mcg of Rhogam (std dose)
genital lesions
HSV - …LAD, often classic vesicles are absent
- ulcerations can be of various sizes, can have
purluent eschar
- negative urine culture, leukocytes, erythrocytes on UA - inflammation of genital tract
- initial - seronegative for HSV antibodies
- recurrences of herpes become less frequent over time (and are usu due to HSV2) - as cell-mediated immunity improves
- recurrences are less painful, less problematic, no systemic sxs, but still prodrome
- gold std ddx - culture, high specificity, low sensitivity (wont catch all cases)
- pregnant women with a hx of genital HSV should receive ppx acyclovir (or valA) at 36wks
- dont do a speculum exam in a person with active herpes lesions
- 1 and 2 can cause meningitis, 1 lives in trigeminal DRG –> temporal encephalitis in adults
H. ducreyi (painful) - large, deep ulcers with exudate, severe possibly suppurative LAD
- infectious
- organisms clump in long parallel strands, school of fish
** painless
Granuloma inguinale (rare in US)- Klebsiella
- ulcerative lesions w/o LAD
- gram neg intracytoplasmic cysts, Donovan bodies
Treponema pallidum (painless) - single ulcer (nonexudative), (then can progress to other systemic findings)
- indurated
- can also have macular (copper penny) rash on palms and soles
- corkscrew organisms on dark-field microscopy
- nontreponemal tests (RPR, VDRL) - can be negative in early infection
- treponemal tests (FTA-ABS) - greater sensitivity in early infection
- treat with IM penicillin G (all stages of syphilis are treated with penicillin)
- repeat nontreponemal serology in 2-4 wks to establish baseline titers - recheck in 6-12 mo, titers should have decreased 4x
Chlamydia trach L1-L3 (lymphogranuloma venereum) - small, shallow ulcers
–> large painful coalesced inguinal LNs (buboes)
condyloma accuminata = HPV
- cauliflower-like, exophytic (can bleed)
- treat with trichloroacetic acid, high recurrence rates
condyloma lata = syphilis
- flat, velvety lesions at intertriginous areas
lichen planus - pruritic, glassy, bright red erosions
- oral lesions, alopecia, extragenital rashes
- high potency corticosteroids + supportive therapy
side note - give hep B vaccination to high risk pts
in the presence of 1 STI - offer testing for all STIs
if someone with a single partner comes in - measure probes for gonorrhea and chlamydia but no need to start treatment immediately
- they are not high risk enough
contraindications to breastfeeding
contraindications - active untreated TB, maternal HIV infection, herpes breast lesions, active varicella infection, chemo/rad, active substance abuse (including MJ), galactosemia in infant
- THC concentrated in breast milk - decreased muscle tone, sedation in infants, delayed motor development at 1 yr
- interesting - hep C is not transmitted in breast milk
- for mom with hep B - give baby HBIg and HBvaccine and then breast feed
Mg tox
uses - seizure ppx in moms, CP prevention in premies (give to mom)
Mg + CCB –> potentiates hypotension
excreted by the kidneys
clinical features - nausea, flushing, headache, hyporeflexia
- mod features - arreflexia, hypocalcemia (Mg temporarily suppresses PTH secrection), somnolence
- severe - respiratory paralysis, cardiac arrest
treat - stop Mg therapy, give IV cal gluconate bolus
fetal birth defects
fetal hydantoin syndrome - due to exposure to anticonvulsants (phenytoin and carbamazepine), midface hypoplasia, microcephaly, clefts, digital hypoplasia, hirsuit, developmental delay
- fetal alcohol syndrome is very similar - except infants will have hyperactivity or mental retardation and hirsuit and clefts are absent
congenital syphilis - rhinitis, HSM, skin lesions
- later findings - keratitis, Hutchinson teeth, saddle nose, saber shins, deafness
- other adverse fetal outcomes include IUGR and fetal death
congenital rubella - deafness, cardiac defects, HSM, microcephaly, cataracts
amniotic band sequence- limb defects, craniofacial defects, abd wall defects
postpartum period
- normal things
NORMAL - rigors, chills, peripheral edema, lochia rubra, uterine contraction and involution, breast engorgement (pt will have fever)
routine care - ..serial examination for uterine atony/bleeding, voiding trial
- check for PP hemorrhage - boggy uterus, heavy vaginal bleeding, unstable vitals
- difficulty void after delivery is common - due to anesthesia, pudendal nerve palsy, periurethral swelling
depression - 10X increase in estrogen and progesterone in pregnancy
- drops to normal during PP period (estrogen is an antidepressant)
- women feel great in the 2nd trimester
loss of libido - extremly common
- treat with counseling and reassurance
- side note - flibanserin is use in premenopausal women for hypoactive sexual desire disorder
postpartum hair loss affects 40-50% of women - estrogen levels during pregnancy increase hair growth (synchronous, in the same phase)
- side note - progesterone and other combo OCPs can have hair loss as a side effect
preterm labor
risk factors - prior preterm delivery, multiple gestation, short cervical length, cervical surgery (particularly cold knife conization, others not so much), cigarette use, obesity, advanced maternal age
why? - *idiopathic, dehydration, uterine distortion can contribution,
screening and prevention - cervical length measurement by TVUS (second trimester), progesterone administration, cerclage placement (cervix is stitched close)
- no hx of preterm labor and short cervix - vaginal progesterone
- pos hx and normal cervix - IM progesterone and serial TVUS-CL until 24 weeks
- pos hx and short cervix - IM progesterone, cerclage and serial TVUS-CL until 24 weeks
- cerclage contraindicated if contractions, gestational age >24 wks, or lethal fetal anomalies
- note - during third trimester, cervix begins to efface and cervical length measurements cant be used to predict preterm birth
fetal fibronectin test and shortened cervix associated with increased risk of preterm delivery
- fetal fibronectin is high until 20 weeks, low during second and third trimesters, increase at term (when contractions disrupt the decidual-chorionic interface)
- so elevated levels prior to term (22-34 wks) are suggestive
- levels in first trimester are not useful
- good negative predictive value (99% in sx women, 96% in asx women)
ferritin will be in amniotic fluid - ferritin is an acute phase reactant, sign of spont preterm delivery
GA 34-37
- give betamethasone (optional), penicillin for GBS pos or unknown
- tocolytics (such as indo and nifedipine) are CONTRAindicated - indomethacin leads to oligo and closure of PDA, nifedipine can cause mat hypotension and tachy (nifedipine also linked to fetal hypoxia and decreased uteroplacental blood flow)
GA 32-34 - betamethasone, tocolytics (1) nifedipine, 2) indo), penicillin as appropriate
- betamethasone - associated with decreased intracerebral hemorrhage and nec enterocolitis
<32 - betamethasone, tocolytics (give nifedipine, NOT terb), MgSO4 (CP ppx), penicillin as appropriate
- Uwise says to give amp if pt’s GBS status is unknown - continue this until status becomes known or labor stops
in general - prenatal corticosteroids are not indicated for previable fetuses (<23/24 wks)
can give 17-hydroxyprogesterone is indicated in pts with hx of preterm birth
PCOS
criteria (2/3)
- chronic anovulation
- hyperandrogenism (clinical/biologic)
- PCO
comorbidities include - metabolic syndrome, OSA, non-alcoholic steatohepatitis, endometrial hyperplasia (due to unopposed estrogen), cancer
GnRH (not pulsatile) and estrogen will be increased, FSH will be normal
- testosterone will also be increased
- LH/FSH imbalance leads to lack of LH surge –> failure of follicle maturation
progesterone level to see if lady is ovulating
treatments - weight loss, OCPs or clomiphene citrate
- OCPs - increase SHBG –> less free testosterone
- clomiphene blocks estrogen receptors in the hypothalamus –> inhibits negative feedback mechanism
hyperthecosis - more severe form of PCOS
- more difficult to treat
amenorrhea
PRIMARY #1) axis intact, uterus present
female athlete triad - amenorrhea, osteoporosis, eating disorder
for exercise induced - FSH nl, estrogen low (so clomiphene wont work)
anovulation - secondary to morbid obesity
- FSH, LH normal
- ovaries are producing estrogen but PROGESTERONE is NOT being produced
imperforate hymen - presents as bulging membrane (due to mucous collection)
- cyclic lower abd pain + NO vaginal bleeding
- pelvic pressure, back pain, or defecatory rectal pain
- side note - pts with abnormal genital tract development should be evaluated for associated renal abnormalities with US
can have vaginal or cervical atresia
transverse vaginal septum - normal vaginal opening with short blind vagina and pelvic mass
*********** #2) axis intact, uterus absent
Mullerian agenesis - WILL have ovaries
AIS/testicular feminization
- testosterone is peripherally converted to estrogen –> YES secondary sex characteristics
- remove testes after puberty
************* #3) axis absent, uterus present
Kallmans - no GnRH
craniopharyngiomas - no FSH, LH
primary ovarian insufficiency - pts will have a hx of autoimmune disorder or Turners
- menopause before 40 - pts will present with amenorrhea, hot flashes, and vaginal atrophy
- fertility treatments = in vitro fertilization or oocyte/embryo donation
SECONDARY - no menses for >3 cycles or >6 mo
- UPT
- check prolactin, TSH, FSH
- hysteroscopy only indicated if pt has a hx of prior uterine infection or procedures
premature ovarian failure - FSH and LH levels are elevated
- FSH > 40, LH > 25
- can be secondary to chemo and radiation (cryopreservation to preserve fertility)
post-pill amenorrhea - women with a hx of IRREGular cycles will have amenorrhea post OCPs
prolactinoma - secondary amenorrhea or nipple discharge
functional hypothalamic amenorrhea -… no vasomotor sxs
placenta problems
abruptio placenta - women with PPROM or preeclampsia/HTN are at increased risk
- other risk factors - cocaine and tobacco use, abdominal trauma
- polyhydramnios with rapid decompression
- hx of prior abruption
- sudden onset painFUL bleeding (abdominal, back pain)
- presents with uterine tenderness and distention, abnormal uterine contractions (high freq, low amplitude, blood has uterotonic effect), fetal distress (due to poor placental perfusion)
- ddx clinically, can use US to rule out placenta previa
- hemorrhage –> reduced blood flow to periphery and uterus (no accels on FHR)
- manage with IVF resuscitation + left lateral decubitus position - complications - DIC (due to tissue factor release) and hypovolemia shock
placenta previa - ddx on routine prenatal US, painless vaginal bleeding
- risk factors are multiparity and advanced maternal age, prior placenta previa, uterine surgery, smoking
- presents with PAINLESS antepartum bleeding
- treat with pelvic rest (intercourse can cause pelvic contractions –> shear placenta off at internal os –> bleeding)
- may resolve in the 3rd trimester - because the lower uterine segment grows
- C-section delivery usu scheduled for 36-37 weeks gestation
vasa previa - fetal vessels over internal os, risk of injury during amniotomy
- painless
- risk of vasa previa - multiple gestations and placenta previa
- rapid deterioration of fetal heart tracing (blood loss is fetal in origin)
PID
frequently asymptomatic - so screening recommended for sexual active women < 25 and women >25 with risk factors
gonorrhea - classically associated with mucopurulent cervicitis exacerbation during and after menstruation
PID - lower abd pain, abnormal bleeding, CMT, fever, mucopurulent discharge
- intermenstrual spotting or post-coital due to cervicitis (cervical friability)
- if pt has hepatic involvement (FHC) –> RUQ pain and pain during inspiration
- to treat PID with perihepatitis - hospitalization and IV antibiotics
PID is a cause of secondary dysmenorrhea - consider pt sexual hx
treat gono/chlamydia with third gen ceph + azithro and doxy
- if you know you only have chlamydia - give only azithro
- otherwise (even if you only have gono) - treat fully
- why? - because gonorrhea is becoming resistant to ceftriaxone - positive chlamydia NAAT also requires treatment PARTNERS
cefoxitin + doxy is broad spectrum - provides polymicrobial coverage for PID
- give bid for 1 week
rare after first trimester - because cervical mucous and decidua seal off and protect the uterus from pathogens
when would you admit a pt?
- pregnancy, failed outpt treatment, inability to tolerate po, noncompliant, severe presentation, or complications (FHC, tubo-ovarian abscess)
- IV cefoxitin or cefotetan + po doxy
note - acute cervicitis presents with mucopurulent (yellow) d/c and vaginal spotting or postcoital bleeding
- often preceded PID (disrupts genital tract barrier)
- gono and chlamydia
- test or both of these orgs –> treat based on this
- treat uncomplicated cervicitis ceftriaxone 125 mg
acute salpingitis - lower abd pain, adnexal tenderness, can see masses on pelvic exam, fever, CMT, vaginal discharge
for tubo-ovarian abscess - add metro
pharyngitis with fever and lower abd pain = gonococcal pharyngitis + PID
(- v.s. mono which would have exudative pharyngitis and tender cervical LAD, rash, splenomegaly)
when would you c-section
fetal distress (category 3 tracing and remote from delivery), breech presentation, multiple prior C-sections
after maternal trauma if - imminent maternal death, to assist with CPR in mom, due to category 3 tracing
PGs - cervical ripening, contraindicated in pts with hx of c-section due to increased risk of uterine rupture
ovarian torsion
risk factors - precipitating factor (exercise)+ ovarian mass, women of repro age, infertility treatment with ovulation induction
presents - sudden onset unilateral pelvic pain, N&V, sometimes palpable adnexal mass
adnexal mass with absent Doppler flow to ovary
- but according to UWISE - if you suspect ovarian torsion DONT get doppler
- because normal blood flow does not rule out ovarian torsion
- escalate to surgical exploration
treat - lap detorsion, ovarian cystectomy, oophorectomy (if necrosis or malignancy)
- you would only drain a cyst if it is large, simple, and there is little likelihood of malignancy
to help with - clomiphene citrate…
ovarian masses
risk factors for cancer - …white race, increasing age, residence in NA or N. Europe
- NOT smoking
- OCPs that cause anovulation are protective
functional ovarian cysts = smaller, simple cysts
serous (uniloculated?) and mucinous (multiloculated) - larger
cystic teratoma - hyperechoic nodules and calcifications, surgically resect
- median age 30, most common tumor in women of all ages
- typically dont rupture
- side note - signs of rupture are peritoneal signs = pleurtiic chest pain, rigid abdomen, rebound, involuntary guarding
epithelial tumors (90%) - typical in 60s
germ cell tumors - ages 10-30
theca-lutein cyst - due to stimulation by bHCG
- multiseptated bilateral cystic masses
- present IN pregnancy or moles, regresses spontaneously after delivery
granulosa(-theca) cell tumor - large adnexal mass
- child - precocious puberty
- postmenopausal woman - bleeding, endometrial hyperplasia
- other features - breast tenderness
sertoli-leydig - 20-40, unilateral
- suppression of FSH and LH, elevation of testosterone
luteomas - large (6-10 cm) yellow or yellow-brown masses (with areas of hemorrhage), 50% are bilateral, will regress spontaneously after delivery
- hyperandrogenism in pregnancy
- symptomatic maternal luteoma puts female fetus at high risk of virilization
- watch luteoma for mass effect consequency
Krunkenburg tumor - bilateral solid ovarian masses on US, mets from primary GI
prognosis - by stage and volume of residual disease following surgery
- histology is important - poorly diff or clear cell tumors have worse survival
treatment - op and post-op chemo + taxane and platinum adjuncts
Mittelschmerz
reccurrent mild, unilateral mid-cycle pain prior to OVULATION
- for example, severe LLQ pain
can occur with every cycle or just be a single episode
side notes - appy is RLQ pain and fever
- ovarian torsion - severe unilateral pain and an adnexal mass
side note - mid-cycle bleeding occurs during ovulation - due to a drop in estrogen
BRCA and ovarian cancer
AD inheritance, Ashkenazi Jew
risk modification - bilateral salpino-oophrectomy in premenopausal women (most effective), OCP, age < 30 aft first live birth, breastfeeding, tubal
- BSO is not routinely recommended to prevent OVARIAN cancer in pts wo a hereditary increased risk
liver problems in pregnancy
HELLP
- hemolysis, elevated liver enzymes, low plts - severe type of preelcampsia
- due to abnormal placentation –> systemic inflammation and activation of coagulation cascade
- microangiopathic hemolytic anemia - particularly detrimental to liver
- liver problems include centrilobular necrosis, hematoma formation, and thrombi in portal system –> distention of hepatic capsule –> RUQ pain - pt presents with preeclampsia, N&V, and RUQ pain
- treat with delivery (at > 34 wks or when appropriate), Mg for seizure ppx, antiHTNs
- note - ppx transfusion at 20K plts, preop transfusion at <40K plts
Acute fatty liver of pregnancy -can cause hepatic failure in third trimester or early PP
- malaise, RUQ pain, N&V, sequelae of liver failure
- prolonged PT and PTT, encephalopathy
- hypoglycemia
- AKI
- possible DIC
- can look like HELLP but these pts will have NOT have severe HTN and will have extrahepatic complications
Intrahepatic cholestasis of pregnancy - pruritus, hyperbilirubinemnia, transaminitis
- ddx of exclusion
- side note - alk phos is normally elevated in pregnancy
- pruritis resolves in the weeks following delivery, prescribe ursodeoxycholic acid prescribed during pregnancy (can start with antihistamines and other topical for initial anti-itch relief)
- early delivery is recommended once fetal maturity is achieved to avoid fetal complications - intrauterine demise, NRDS
side note: elevated alk phos is elevated in normal pregnancy
intrauterine fetal demise
recurrent pregnancy loss - >2 consecutive or >3 total spont losses before 20 wks gestation
= absence of fetal cardiac activity on US
- 50% of cases have no etiology
- HTN and APAS - oligo and intrauterine GR
- APAS - workup with anticardiolipin and b-2-glycoprotein antibody, PTTP, russell viper venom time
- mat hypothyroidism - increased risk of miscarriageb
- blood antibody screen can tell if maternal alloimmunization was the cause
- Kleihauer-Betke can tell of fetomaternal hemorrhage
risk factors - nullip, obesity, HTN, DM
treat
- 20-23 wks - dilation and evacuation or delivery
- > 24 wks - delivery (can be delayed until the pt is ready)
- autopsy and karyotype, microscopic placental evaluation, inspect membranes and cord
- after the fact - check mom for antiphospholipid antibody syndrome and fetomaternal hemorrhage (Kleihauer-Betke)
complication - coagulapathy after several WEEKS of fetal RT
- check coag panel, serial fibrinogen levels
CAH
classical - salt-losing crisis, virilization
nonclassical (21-hydroxylase deficiency):
oligoovulation, hyperandrogenemia (hirsuit), increased 17-OH-progesterone levels
- can also have mineralocorticoid excess - hypertension, hypokalemia
- precocious puberty in boys
androgen excess impairs hypothalamic sensitivity to progesterone –> rapid GnRH secretion –> hypersecretion ofLH and FSH –> increased gonadal steroid production
pelvic organ prolapse
cystocele, rectocele, enterocele, procidentia (uterus and vaginal walls herniate through the vagina), apical prolapse (uterus, vaginal vault)
- can also present with tissue damage - erosions
risk factors - obesity, multip, hysterectomy, post-menopausal age
features - pelvic pressure, obstructed voiding or incontinence
- pts have to put vaginal pressure to void
management - weight loss, pelvic floor exercises, vaginal pessary, surgical repair (required if there is complete herniation)
pt comes in with vaginal bleeding
but has a thin endometrial stripe - no need for endometrial bx
but you would want to bx in a post-menopausal or perimenopausal woman
estrogen-progestin contraceptives
benefits - endometrial and ovarian cancer risk reduction, reduction in risk of benign breast disease, …
- decreased risk of endometrial cancer due to progestin
- decreased risk of ovarian cancer due to ovulation suppression
risks - VTE, HTN, hepatic adenoma, stroke and MI (rare)
- why HTN - increased angiotensinogen synthesis by estrogen during hepatic first-pass metabolism
- side note - hepatic adenoma –> intra-abdominal bleeding + peritonitis –> immediate surgical intervention
Gartner duct cyst
due to incomplete regression of Wolffian duct - single or multiple cysts (submucosal) along lateral upper anterior vagina
Bartholin cyst
asymptomatic - no intervention, observe
symptomatic - I&D,
- same for Bartholin abscess - note for abscess, only add abx if you cellulitis is present
- Word catheter
vaginitis
BV (pH > 4.5) - po metro or clinda for pt
- side note - TMP is a dihydrofolate reductase inhibitor (risk of fetal malformations)
- metro po for 10 days
Trichomoniasis (pH >4.5) - thin, yellow-green discharge
+ significant vaginal and vulvar inflammation, strawberry cervix (erythematous patches on cervix)
- po metro for pt AND her partner
- single dose 2 grams or 500mg bid 7 dyas
candida - normal pH
+ vulvar erythema and excoriations
- microscopy may be negative in 50% of cases
vulvovaginal candidiasis
- risk factors - DM, immunosuppression, pregnancy, OCPs, antibiotic use
- estrogen increases the risk of candidiasis
note - dont use metronidazole with alcohol –> disulfuram-like reaction
ovarian reserve with aging
optimal fertility = 18 yo
decreased fertility = 37 yo
end of fertility = 41 yo
irregular cycles starting at 45
infertility - lack of conception after 6 mo of intercourse in a woman > 35 yo
FSH testing on day 3 (early follicular phase)
Pap and f/u
co-testing preferred in women 30-65
in general - all abnormal pap smear results + pos HPV –> colpo
- ASCUS –> reflex HPV testing
- repeat cytology in 1 year is also acceptable if HPV testing cant be done
- HPV testing negative –> routine screening in 3 yrs
ASCUS or LSIL –> HPV co-testing
- high-grade HPV –> colp
HSIL (concerning for CIN2 or worse) –> immediate colp (or LEEP if the pt is not pregnant)
colp - apply acetic acid –> aceto-white changes will occur on abnormal cells
endocervical curettage if colp was “inadequate” - not performed during pregnancy because it is an invasive procedure
cervical neoplasia typically occurs at the transformation zone
note - HPV testing is not recommended for ages 21-29 because most HPV infections clear spontaneously in these pts
women who have hx of cervical cancer, have HIV, or were exposed to DES dont follow regular guidelines
***
when would you do embx?
- for >45 - abnormal uterine bleeding, postmenopausal uterine bleeding
- <45 - unopposed estrogen (obesity, anovulation), failed medical management, Lynch syndrome
- > 35 - atypical glandular cells on pap
note - endometrial stripe of <4mm excludes endometrial cancer in postmenopausal pts with AUB, cant reliably do so in premenopausal pts (?)
after hysterectomy - still need bimanual and rectovaginal exam
physiologic changes during pregnancy
blue cervix = Chadwicks sign - due to increased blood flow to the cervix
many changes are mediated by PROgesterone
- progesterone causes smooth muscle dilation (?)
renal and urinary changes
- increased RBF and GFR
- also increased renal BM permeability
- -> decreased serum BUN and Cr, increased renal protein excretion, increased Na excretion
- increased ADH release from pituitary
R>L hydronephrosis
- due to sigmoid colon cushioning on the left
- greater compression of the R ureter due to uterus and right ovarian vein complex
note - renally excreted meds (gabapentin) need to be closely monitored
heme - decreased protein S activity, increased fibrinogen and coag factors, increased resistance to activated protein C
gestational thrombocytopenia = normal
CV - increased cardiac output and HR, decreased SVR and decreased BP
- when would you work up a murmur in pregnancy - holosystolic mitral murmur
- mitral stenosis can worsen during pregnancy, can present with AF with RVR and cough, progressive dyspnea, and orthopnea (consider rheumatic fever)
pulm - chronic respiratory alkalosis with metabolic compensation increased PaO2 and decreased PaCO2
- why? due to increased tidal volume and minute ventilation (RR is unchanged)
if pregnant woman complains of SOB during exercise think = physiologic dyspnea of pregnancy
asthma worsens in pregnant women
- move to next line of treatment if mom is using b-agonists more than 2x/wk
- next line - add inhaled corticosteroids or cromolyn sodium
- subQ terb and systemic corticosteroids in acute cases
thyroid - total T4 increased, free T4 will be unchanged, TSH decreased (feedback inhibition)
- high TRH –> stimulates prolactin secretion –> inhibits GnRH –> low FSH and LH
- bHCG stimulates thyroid hormone in the first trimester
- estrogen stimulates TBG
- BUT pt is clinically euthyroid
- pts with Hashimotos or other impaired thyroid function - cant increased thyroid hormone –> relative hypothyroidism (so levothryoxine needs to be increased during pregnancy)
back pain - benign
- rule out preterm labor and pyelo
AFP
produced by fetal yolk sac, liver, and GI tract
- confirm gestational age - AFP levels change with age
increased
- under-dating
- open neural tube defects (rel rare)
- ventral wall defects
- multiple gestation
- fetal demise
- -> next steps are to obtain an US
decreased
- aneuploidies - 21, 18
- 21 - low AFP, low estriol elevated bHCG, elevated inhibin
- 18 - low AFP, very low estriol, low bHCG, normal inhibin
abnormal quad screen –> can offer cell-free fetal DNA testing (DNA is in maternal plasma)
- perform US
shoulder dystocia
ob emergency
risk factors - fetal macrosomia (>4000 g), maternal obesity (and excessive pregnancy weight gain), GDM, post-term pregnancy, prolonged second stage of laber, prior hx
warning signs - protracted labor, retraction of fetal head into perineum after delivery (turtle sign)
conversely - HTN and short interpregnancy interval (<18 mo) are risk factors for FGR
management = BE CALM
- breathe, dont push
- elevate hips against abdomen (flattens sacral promontory)
- call for help
- apply suprapubic pressure
- episiotomy
- maneuvers - deliver posterior arm –> rotate 180 –> collapse anterior shoulder –> replace fetal head into pelvis for c-section (last)
complications
- fractured clavicle - decreased moro reflex due to pain on affected side
- fractured humerus - again decreased moro due to pain
- Erb-Duchenne palsy (C5-C6) - decreased moro AND biceps reflexes, intact grasp
- 80% of pts have spontaneous recovery wi 3 mo, treat with gentle massage and physical therapy - Klumpke palsy (C8 and T1) aka claw hand and absent grasp (hand paralysis), Horners, intact reflexes
- perinatal asphyxia - AMS, respiratory/feeding difficulties, poor tone, seizure
- perinatal stroke - hyperreflexia and hypertonia
PP urinary RT
why? - because of bladder atony
risk factors - nulliparity, prolonged labor, perineal injury, regional analgesia, C-section, instrumental vaginal delivery
- sacral nerve “depression”, pudendal nerve palsy, perineal edema
clinical features - RT and dribbling
- confirmed by inability to void for 6 hrs after delivery
- or if cath produces >150 mL urine
manage - analgesics, ambulations, cath
epithelial ovarian carcinoma
risk factor - BRCA, age, use of fertility drugs, uninterrupted ovulation
sxs -…. and SOB (due to ascites)
elevated CA-125 - useful in POSTmenopausal women (low specificity in premenopausal women)
- leiomyomata, endometriosis cause elevated CA-125
findings on US - solid mass, thick septations, ascites
- originates from ovary, fallopian tube, and peritoneum
- with pelvic and abdominal mets
- side note - peritoneal fluid in postmenopausal women is pathologic
steps: 1) US, 2) CA-125, 3) further imaging
manage with - ex lap for resection, staging, and inspection
- chemo with platinum-based agents following surgery
- DONT do image-guided biopsy - seding
Wernicke encephalopathy
chronic alcoholism, malnutrition, hyperemesis gravidarum
- hyperemesis gravidarum - hypochloremic metabolic alkalosis, hypokalemia, hypoglycemia, elevated serum LFTs
- and concurrent volume contraction metabolic alkalosis
features - encephalopathy, nystagmus or bilateral abducens palsy, gait ataxia
treat with IV thiamine and then glucose
- glucose infusion prior will worsen Wernickes
side note - neurosyphilis will show tabes dorsalis (sensory ataxia, lancinating pain) and Argyll Robertson pupils (constrict to accommodation but not light)
breast cancer
1/8 lifetime risk
risk factors - HRT, nulliparity, increased age at first live birth, *alcohol consumption (dose-dependent effects)
BRCA increases risk in premenopausal women
non-modifiable risk factors - genetic mutations/first degrees relatives with breast cancer (<50), white race, increasing age, early menarche or late menopause
- bilateral mastectomy can be offered to BRCA carriers
late and post-term pregnancy complications
late-term = 41-42 weeks
past 42 weeks - post-term pregnancy
risk factors - nulliparity, hx of prior postterm pregnancy, maternal obesity, fetal anomalies, fetal adrenal hypoplasia, anencephaly, inaccurate dates
fetal - oligo, meconium aspiration, stillbirth, macrosomia, convulsions, uteroplacental insufficiency, dysmaturity
- why oligo? - aging placenta –> decreased fetal perfusion –> decreased renal perfusion…
maternal - C-section, infection, PPH, perineal trauma
- emergent C-section is advised if there are signs of fetal distress or oligo
if mom comes in at 40 weeks and is uncomfortable - it is reasonable to induce
- why? - because waiting longer may increase risk of perinatal mortality (perinatal mortality increases at 41 weeks gestation)
- beginning at 41 weeks - some practioners do 2x/wk testing with amniotic fluid volume (so BPP)
for a mom with a favorable cervix at 41 weeks gestation - induce
fetal dysmaturity - increased incidence after 43wks
- withered, meconium stained, long-nailed, fragile, with small placenta
- greatest risk for stillbirth
illicit drug abuse in pregnancy
all pts should be screened for illicit drug use - f/u with serial urine drug tests
risk factors - adolescent pregnancy, late/noncompliant RPN, inadequate pregnancy weight gain
ob complications - spont abortion, preterm birth, preeclampsia, abruptio placentae, FGR, intrauterine fetal demise
- threatened abortion - vaginal bleeding, closed cervix, fetal heart beat
decreased fetal movements
decreased fetal movements - concerned about fetal compromise
- -> NST - reactive test means that there are 2 accelerations in 20 min
- reactive NST has a high negative predictive value
- -> further testing for nonreactive stress test
- usu due to fetal sleep - use vibroacoustic stimulation to awaken the fetus
uterine inversion
cause of PPH
- usu accompanied by hemorrhagic shock and lower abd pain
risk factors - nulliparity, fetal macroscomia, placenta accreta, rapid L&D
treatment - aggressive fluid replacement, manual replacement of the uterus
- THEN placenta removal and uterotonic drugs (because uterine atony is commonly encountered) after uterine replacement
breech
confirm with transabdominal US
- most fetus are vertex by 37wks (<4% are breech)
risk factors - prematurity, multiparity, multiple gestation, uterine anomalies, fetal anomalies (hydrocephaly, anencephaly), abnormal placentation, polyhydramnios
ECV at >37 weeks gestation
- contraindications to ECV - active labor, ROM, abnormal fetal HR tracing, oligohydramnios (or decreased amniotic fluid), placental abnormalities, hyperextended fetal head, multiple gestation, fetal or uterine abnormality
internal podalic version - used for breech extraction of malpresenting second twin
(- contraindicated in active labor)
frank breech most common = butts first
2 incomplete breech
3 complete breech
forceps are use to assist in flexion of after coming head
vacuum - contraindication
contraindications to vaginal delivery
placenta previa, active herpes lesions, prior classical c-section
ABO hemolytic disease
infants with A or B, mom is O
MILD (why mild - because A and B antigens are present on blood cells and cells of other fetal tissues–> neutralizes the antibody response)
jaundice w/i 24hrs of birth, anemia, increased retics, hyperbilirubinemia, positive Coombs
reaction to A or B during pregnancy –> IgM
- but a person with blood type O has been exposed to A/B antigens early in their life –> they have IgG in their bloodstream, this can cross the placenta
manage - serial bili, oral hydration and phototherapy for most neonates
- exchange transfusion for severe anemia/hyperbili
fetal growth restriction
weight < 10% for GA
- on delivery - thin, loose skin, thin umbilical cord, wide anterior fontanel
- cause may be anything –> utero-placental insufficiency is the result (so examine placenta)
- severe IUGR is <3%
1st trimester onset (something is wrong with baby) - chromosomal abnormalities, congenital infection
- growth lag
- look for hints - ASD hints at chromosomal abnormalities
- intracerebral calcifications and ventriculomegaly + maternal illness hints at infection
2nd/3rd trimester abnormalities (something is wrong with mom, more common) - utero-placental insufficiency (HTN, DM), maternal malnutrition (tobacco use)
- head-sparing growth lag
cocaine, tobacco, and alcohol also associated with FGR
neonatal complications - polycythemia, hypoglycemia, hypocalcemia, poor thermoregulation
consequences for baby in the future - increased risk of developing CVD, HTN, stroke, COPD, DM2, obesity
manage with once-twice weekly biophysical profiles, serial umbilical artery Doppler sonography, serial growth US
- many pts will have oligo (2/2 fetal anemia)
- S/D ratio of umbilical artery by doppler - increase reflects increased vascular resistance
delivery indicated for fetus with IUGR at 36 wks - with oligo and abnormal umbilical artery doppler studies
- regardless of fetal lung maturity
GDM
fasting < 95
1-hr postprandial <140
2 hr postprandial < 120
screen ALL at 24-28 weeks gestation
- screen earlier for pts with obesity, previous GDM, previous macrosomic infant and again at 24-28 weeks
treatment - 1) diet, 2) insulin, metformin, glyburide (other meds have shown adverse effects in infants)
- insulin doesnt cross the placenta
neonatal acidosis occurs with poor glycemic control
epidural
in 10% of cases - anesthesia will result in hypotension due to vasodil and venous pooling
treat with aggressive IVF volume expansion prior to epidural placement
- left uterine displacement - to improve VENOUS return
- vasopressors
side note - anesthesia can ascend toward the head –> brain stem depression
ectopic pregnancy
criteria
1) fetal pole outside uterus
2) bHCG over discriminatory zone and no IUP
3) pt has bHCG increase of <50% in 48hrs and levels dont fall after D&C
note- thick endometrial stripe suggestive of intrauterine pregnancy?
greatest risk factor is prior hx of ectopic
features - abdominal pain, vaginal bleeding (can be spotting over several days), hypovolemic shock if ruptured
- CMT, adnexal tenderness, or abdominal tenderness
- palpable adnexal mass
rare type of ectopic - cornual or interstitial ectopic pregnancy
- gestational sac is supposed to implant in the upper fundus
- cornual area as abundant blood supply –> ectopic can lead to life-threatening hemorrhage
ddx by TVUS
- discriminatory zone - … below –> repeat bHCG in 2 days
- above –> repeat bHCG and TVUS in 2 days
- bHCG will double every 2 days for viable pregnancy
treatment - methotrexate in stable folk, surgery for unstable
methotrexate IF
- hemodynamically stable
- non-ruptured
- size of ectopic <4cm wo HR or <3.5 cm w HR
- normal liver enzymes and renal function
- normal WBC
- ability for rapid f/u
in pts with hemoperitoneum and unstable vitals (hypotension and tachy) - requires emergency surgical exploration
misoprostol
=PGE1
causes cervical dilation and myometrial contraction = aka ripening
useful to treat incomplete or missed abortion
mifepristone - progestin receptor antagonist
- used for emergency contraception, prevents ovulation
- used with misoprostol for pregnancy termination
mole
presents - abnormal vaginal bleeding +/- hydropic tissue
- theca lutein ovarian cysts
- hyperemesis gravidarum
- preeclampsia with severe features
- hyperthyroidism
- partial mole will more likely be diagnosed as a missed or incomplete abortions
dont rule out mole based on a single bHCG value
risk factors - extremes of maternal age, hx of past mole, asian race, increased in women with 2+ miscarriages
- risk of second mole = 1-2%
- risk of 3rd mole = 10%
snowstorm appearance - anechoic, cystic spaces
dont want to biopsy - these lesions are highly vascular
treat - … contraception
- persistent disease can be easily cured with chemo
if you are concerned about mets - get CT first abd/pelvis (may get brain MRI)
pt wants to get pregnant after a mole - wait at least 6 mo after negative b-HCG levels (GTN is rare after 6 mo post suction curettage)
if gestational trophoblastic neoplasm develops - use methotrexate or hysterectomy
abnormal uterine bleeding following menarche
due to immature HPA
- normally estrogen build endometrium –> corpus luteum produces progesterone –> corpus luteum degeneration and progesterone withdrawal produces menses
in AUB following menses - menses like bleeding occurs because of estrogen breakthrough bleeding
can treat with progestin-only or combo contraceptives
- but will usually resolve 1-4 yrs postmenarche
OCPs/contraception
side effects and risks
- breakthrough bleeding
- breast tenderness, nausea, and bloating
- amenorrhea
- HTN, VTE
- decreased risk of ovarian and endometrial cancer
- INCREASED risk of cervical cancer
- hepatic adenoma
- increased triglycerides (due to estrogen)
can be used >6 weeks PP while breastfeeding
OCPs will decrease risk of ovarian AND endometrial cancer
- progesterone IUD may decrease a woman’s risk for endometrial cancer only
note - OCPs decrease pain symptoms by thinning endometrial lining, reducing PG, and decreasing uterine contractions
- OCPs and progestins manage AUB in premenopasual pts
- OCPs prescribed in a continuous fashion = no placebo pill so no withdrawal bleeding
Cu IUD - inflammatory reaction, may increase dysmenorrhea and pain symptoms, heavy bleeding
progestin implants - commonly cause amenorrhea
progestin-only pills have a much higher failure rate than the progesterone IUD
medroxyprogesterone (depo)
- inhibits GnRH release
- give every 3 months
- may increase body fat, decrease lean muscle mass, loss of bone mineral density, breast tenderness, fatigue
- initially menstrual irregularities, 50% have amenorrhea after 1 year of use
progesterone - less effective dysmenorrhea and contraception because they dont inhibit ovulation
progesterone stimulates differentiation of endometrial cells and prevents endometrial hyperplasia/cancer
absolute contraindications to combined hormonal contraceptives (worried about estrogen and progesterone)
- migraine with aura
- > 15 cigs/day + >35
- HTN > 160/100
- heart disease
- DM with end-organ damage
- hx of thromboembolic disease, hx of stroke, major surgery with prolonged immobilization, APA syndrome
- breast cancer
- cirrhosis and liver cancer
- use < 3 weeks PP
- women who are lactating
- women who develop severe N&V with OCPs
- these ladies are ideal candidates for progestin-only pills - note progestins should be used cautiously in ladies with hx of depression
most effective contraception with <1% risk of pregnancy
- Depo (medroxyprogesterone acetate)
- sterilization
- LARC - nexplanon (etonogestrel implant, can cause irregular spotting) and IUD
antepartum fetal surveillance
evaluates for fetal hypoxia
NST - 20-40 min, reactive if 2 accels in 20 min
biophysical profile - NST + US assessment for amniotic fluid volume, fetal breathing movement, fetal movement, and fetal tone (x/2 for each category)
- single pocket > 2x1 cm or amniotic fluid index > 5
- > 3 body movements
- > 1 episode of flexion/extension
- > 1 breath for > 30 seconds
- normal result is 8-10/10
- 6/10 - repeat in 24hrs
- 0-4/10 - urgent delivery
- abnormal result indicative of fetal hypoxia due to placental dysfunction
contraction stress test - FHR during contraction
- normal is NO late or recurrent variable decels
- contraindicated in placenta previa or hx of myomectomy
doppler of umbilical artery - for FGR
aromatase deficiency
normal internal genitalia
first manifestation - inability for placenta to convert androgens to estrogens –> maternal masculinization
estrogen absence….
- and high concentration of gonadotropins –> polycystic ovaries
McCune-Albright
cafe au lait spots, polyostotic fibrous dysplasia, autonomous endocrine hyperfunction
gonadotropin-ind precocious puberty
premature menses before breast and pubic hair development
ovarian hyperthecosis
virilization in postmenopausal women
+ insulin resistance
solid-appearing enlarged ovaries
miscarriages/abortions
early pregnancy failure
systemic illnesses - DM (insulin dependent), CKD, lupus, thyroid disease
- APA syndrome - pregnancy loss or demise, give ASA AND heparin in future pregnancies
- APA syndrome - can have vascular thrombosis (TIA, stroke, DVT)
recurrent pregnancy loss
- systemic disease testing
- mom and dad karyotypes
- uterine imaging
missed - no vaginal bleeding, closed os
- will be some visible tissue or fetal pole within the uterus
= retention of nonviable pregnancy for sometime
threatened - vaginal bleeding, closed os, fetal cardiac activity
inevitable - vaginal bleeding, dilated cervical os, US shows intrauterine gestation in lower uterine segment
- incomplete
- complete - vaginal bleeding, closed cervical os
septic abortion
- broad spectrum abx and uterine evacuation (want prompt evacuation)
expectant management is acceptable in early pregnancy loss
D&C
- use this when pt is UNSTABLE
- anesthesia risk, bowel/bladder injury, cervical lac (vaginal bleeding), uterine perf
- uterine perf - increasing lower abd pain, nausea, scant bleeding, fever, rebound tenderness and abd guarding, uterus soft and tender
retained products of conception - PROFUSE vaginal bleeding
hematometra (collection of blood in the uterus) - cyclic midline abd pain
second stage of labor
from 10cm –> delivery
arrest
- > 3 hrs if nullip, >2hrs if multip
- risk factors are maternal obesity and excessive pregnancy weight gain, DM
- etiology - cephalopelvic disproportion, malposition, inadequate contractions, maternal exhaustion
- optimal fetal position is occiput anterior
- inadequate contractions <3 in 10 min (most common cause of protracted first stage of labor)
- treat with op vaginal delivery or C-section
PROM
risk factors for PPROM - genital tract infection, hx of PPROM, smoking
PROM at <34 weeks
- no infection - antibiotics, corticosteroids, fetal surveillance
- infection - antibiotics, corticosteroids, Mg < 32 weeks, delivery
PROM at 34-37 weeks
- antibiotics
- +/- corticosteroids
- delivery
complications - chorio/endometritis, cord prolapse, abruptio placenta
SLE
edema, malar rash, arthritis, hematuria, hypertension, arthralgias
ob complications - preeclampisa, preterm birth, c-section, FGR, fetal demise
SERMs
tamoxifene - treats breast cancer
raloxifene - used in postmenopausal osteoporosis
both - used to PREVENT BC in high-risk pts
adverse effects of tamoxifen and raloxifine - hot flashes, VTE, endometrial hyperplasia/cancer (tamoxifen only)
pubic symphysis diastasis
progesterone and relaxin increase pelvic mobility
risk factors - fetal macrosomia, multip, precipitous labor, operative vaginal delivery
present with difficulty ambulating, *radiating suprapubic pain, pubic symphysis tenderness, intact neuro exam
manage conservatively, pelvic support, PT
RPN
initial - Rh, antibodies
- Hb/Hct, MCV
- would screen for hemoglobinopathies in pts with microcytic anemia
- HIV, VDRL/RPR, HBsAg
- Rubella and varicella titers
(- pap)
- chlamydia PCR
- urine culture and protein
24-28weeks
- Hg/Hct
- antibody screen for Rh negative
- 50 g 1 hr GCT - why HPL increased (to promote fetal growth and metabolism)
- confirm with 3-hr 100g glucose tolerance test
35-37 - GBS culture
side note - treat asymptomatic bacteriuria (>100,000 CFUs) in pregnant pts due to increased risk of ascending infection (aka acute pyelo) (in the first trimester)
- asx bacteruria also associated with preterm labor and low birth weight
- treat with cephalexin, amox-clav (augmentin), nitrofurantoin, fosfomycin
intraductal papilloma
unilateral bloody nipple d/c
single dilated breast duct on mammogram and US
- confirm ddx with biopsy and excision
compare to infiltrating ductal carcinoma - would present with breast mass and LAD
Sjogrens
can be isolated or as a manifestation of another autoimmune phenomenon
sicca syndrome - generalized dryness of mucous membranes
- dental caries, dry eyes, dyspareunia
other manifestations - arthritis, Raynauds, respiratory tract involvement, increased risk for non-Hodgkins lymphoma
oligohydramnios
associated with HTN and placental insufficiency
uterine rupture
= loss of fetal station
FHR - tachy and recurrent decels
emergency laparatomy
TIP
get a pregnancy test before CT/imaging if pt presents with acute onset abdominal pain
ex if you suspect kidney stone - get US of kidney and pelvix
toxic shock syndrome
S aureus, group A strep, superantigen - tampon use, recent surgery, skin lesions/burns, sinusitis/nasal surgery
- superantigen - exaggerated immune response –> shock and multiorgan failure
high fever, hypotension, diffuse macular rash involving palms and soles –> desquamation, vomiting, diarrhea, AMS
supportive therapy, removal of tampon, abx
compare to gonorrrhoeae - pustular dermatitis, tenosynovitis, migratory asym polyarthralgia
puberty in girls
1) breast development - 8-12
2) pubic hair
3) growth spurt
4) menarche approx 2-2.5 yrs after breast bud development, lack of menses < 15 is NORMAL (as long as secondary sex characteristics have been appropriate)
- body weight needs to be 85-106lbs before menses can start
- other things for menses - sunlight and sleep
reevaluate if menarche does not occur by age 15 (16 according to first aid)
OR
if amenorrheic and no secondary sex characteristics at 13 (14 according to FA)
- TSH, pelvic US (look for organs), MRI potentially
when would you get a karyotype - if pt has no breast bud development and amenorrhea
CT abdomen to look for adrenal tumor
- can get cortisol levels
Rokitansky-Kuster-Hauser - vaginal and uterine agenesis
kallmann syndrome - treat with pulsatile GnRH
true precocious puberty - ddx of exclusion
- bone age is greater than chronological age
- increased pulsatile GnRH secretion
- tumors, CNS injury, congenital anomalies
- pos stim test = central lesion, negative = peripheral lesion - treat with leuprolide
idiopathic isosexual precocious puberty - early puberty
first stage of labor
onset of contraction-10cm dilated
- active phase starts at 6cm dilation
- active phase progression - 1(-2)cm/hr
note latent phase is before 6cm dil - prolonged is >20, >14
- treat with rest or augmentation of labor
- DONT do amniotomy because this places pt at a greater risk of infection
adequate contractions - contractions >200 MV units in a 10 min interval (summed)
protraction - cervical change is slower than expected +/- inadequate contractions
- -> oxytocin
- if this doesnt help –> IUPC
arrest - no cervical change for >4 hrs with contractions
OR
no cervical change for >6hrs with inadequate contractions
–> amniotomy
–> oxytocin
–> C-section
scenario - pt is contracting but you are not sure if her contractions are adequate
- IUPC
emergency contraception
note - ovulation on day 14, fertilization possible 24hrs after ovulation
emergency contraception can cause the next period to be irregular
cu iud - 0-120 hrs after intercourse, 99% efficacy (all other methods have less efficacy)
ulipristal pill - anti-progestin, delays ovulation, 0-120hrs (5 days)
levonorgestrel pill (plan B) - progestin, delays ovulation, 0-72hrs following intercourse
OCPs (multiple pills taken simultaneously)- progestin, delays ovulation, 0-72 hrs
pregnancy and exercise
20-30 min of moderate intensity exercise on most/all days is recommended
absolute contraindications - amniotic fluid leak, cervical incompetence, multiple gestation, placenta abruption or previa, premature labor, preeclampsia/gestational HTN, severe heart or lung disease
- so in anything that is NOT normal gestation
unsafe activities - contract sports, high fall risk, scuba diving, hot yoga
malnutrition and pregnancy
typically does NOT affect the quantity or quality of breast milk production
menopause
sxs - ….urinary incontinence and recurrent UTIs, pelvic pressure
- bladder, urethra, pelvic floor muscles, and endopelvic fasica posses estrogen receptors
- urinary sxs (can mimic UTI) - because genital and urinary tracts have a common embryologic origin
- can have petechiae and fissures on exam
on physical - narrowed introitus, loss of labial volume, …
treat with vaginal lubricant and topical estrogen
- Ca daily - 1200mg in postmenopausal women (need increasing amts with age due to lower amts of active vitamin D)
- HRT is the best treatment for severe menopausal sxs - smallest effective dose for shortest time
- estrogen is most effective for hot flashes
HRT - start wi 10 yrs of menopause or younger than age 60
- contraindications - CAD, breast cancer, prior DVT/stroke, liver disease
- risks are increase in breast cancer and reduction in colon cancer
- benefits - increased HDL, lowered LDL
risk factors for osteoporosis - hx of fracture as an adult, low body weight, current smoker, FHx, white or asian, dementia or hx of falls, poor nutrition, estrogen def, alcoholism, insufficient activity
- osteopenia - -1 to -2.5
- BMD and repeat every 2 yrs –> start bisphosphonates
- other treatments - good diet, exercise, stop drinking and smoking
- HRT has not shown benefits wrt osteoporosis
note - if you remove ovaries in post menopausal woman –> she will experience vasomotor sxs again
- because ovary is still producing androgens –> peripherally converted
placenta accreta
placenta attached to myometrium
- risk factors - prior c-section, hx of d&c, maternal age > 35
intraplacental villous lakes on US
if antenatally diagnosed –> planned c-section hysterectomy
dowagers hump
lady with curved spine - think compression fractures
elective c-section
this is allowed
dr should honor this decision - schedule after 39 wks
conflicts of interest
pharmaceutical companies can support conferences where physicians receive CME credit
DEXA
recommended for pts with RISK factors for osteoporosis before 65
osteoporosis
- strongest predictor is FHx
- age >50 (But bone breakdown begins after 35)
- gender
- small-frame, thin
- heavy alcohol consumption
best prevention - regular exercise (weight bearing)
mammograms
ACOG - recommends that women 40+ yrs be offered annual mammograms
US can be used an adjunct
- evaluate inconclusive mammogram findings
- women dense breast tissue
- cyst v.s. solid mass
colonoscopy
high risk individuals -
start at 40
OR start 10 yrs before relative ddx and repeat every 5 yrs
vaccines for pregnant women
recommended - tdap, flu, rhogam
for high risk pts - hep A and B, pneumococcus, H flu (for high risk pts, so HIV, sickle cell dz, prior splenectomy), meningococcus, varicella zoster Ig
MMR, varicella, HPV, live attenuated flu are contraindicated
- can give MMR immediately PP
weight gain during pregnancy
BMI < 18.5 - 28-40lbs gain
18.5-24.9 –> 25-25 lbs
25-29.9 –> 15-25 lbs
> 30 –> 11-20 lbs
Ashkenazi Jews
increased risk for being carriers of cystic fibrosis
- carrier freq is 1/25 in the non-hispanic white population
screening for aneuploidy
first trimester combined test - nuchal translucency, PAPP-A, b-HCG
triple screen - second trimester, AFP, bHCG< uE3
quad screen - second trimester triple + inhibin A
sequential screen - first trimester nuchal translucency and PAPP-A + second trimester quad screen
- second best detection rate, after cell-free DNA
serum integrated screen (when unable to obtain nuchal translucency) - first trimester PAPP-A + second trimester quad screen
cell-free DNA - best for detect of DS, detection rate of 99%
ex: say fetus as increased NT –> next step to rule out anomalies is detailed fetal Us and echo at 18-20wks
most common cause of inherited mental retardation
fragile x syndrome
side note - DS is genetic but the majority of cases are not inherited
diabetes in pregnancy
gestational DM
- risk factors - previous baby >9lbs, hx of abnormal glucose tolerance, pre-pregnancy weight for 110% or more of ideal body weight, ethnicity
initially - start with diet and BG monitoring
- values should be less than 90 fasting, less than 120 1-2hrs post-prandial
babies born to diabetic mothers - increased risk of hypoglycemia, polycythemia and hyperbili, hypocalcemia, and respiratory distress
folic acid supplementation
0.6mg/d
for women with a previous pregnancy complicated by fetal neural tube defect - 4 mg/d
ibuprofen during pregnancy
can take it until 32 weeks - at this time premature closure of DA becomes a risk
woman comes in labor
review prenatal records
vitals and abd/pelvic exam
a speculum exam with nitrazine test to confirm ROM - if pts hx suggests or if pt is unsure
pt cant deliver the baby with one or two pushes but fetus has descended and fetal HR is dropped –> operative vaginal delivery
IUPC
normal contractions - <5 over a 10 min period (averaged over 30 min)
if you place an IUPC and a significant amount of vaginal bleeding is noted - think placental separation or uterine perf
- -> withdraw catheter and monitor the fetus
- if fetal status is reassuring –> try to place IUPC again
umbilical cord prolapse
elevate the fetal head with a vaginal hand - to avoid compression of cord
AND arrange for c-section
DS
flat nasal bridge, small, small rotated ears, sandal gap toes, hypotonia, protruding tongue, Simian creases, epicanthic folds, oblique palpebral fissures
meconium aspiration
if meconium present in the amniotic fluid and the newborn is DEPRESSED –> intubate the trachea and suction meconium, etc. from beneath the glottis
- give surfactant
meconium is present in more postterm pregnancy - 1) greater amt of time in utero, 2) fetal hypoxia
twin-twin transfusion syndrome
occurs in monochorionic pregnancies - most commonly in mono and diamniotic twins
fat twin - plethoric not macrosomic
- polycythemia is a complication for the plethoric twin
- volume overload polyhydramnios –> HF and hydrops
thin twin
- IUGR, oligo
both twins have high risk of death in utero
- surviving twin has increased risk of neurological morbidity and CP
- recipient twin, excess volume - cardiomegaly, tricuspid regurg, v hypertrophy, hydrops fetalis
- donor twin - anemic, high-output HF, hydrops
APGARS
activity pulse grimace, response to stimluation appearance respiration
infant born and shows no respiratory effort
- give pos pressure ventilation and intubate
- -> adjust head to sniffing position, 10L/min O2 flow, ….
DONT give naloxone if mom is on narcotics –> life-threatening withdrawal for infant
mom with HIV
screen in first trimester, screen high risk pts again in the 3rd trimester
testing for viral load and CD4 count (1-3mo)
HAART antepartum and IV zidovudine during labor
- viral load <1000 - continue HAART and vaginal delivery
- > 1000 - zidovudine and c-section
start AZT (zidovudine) immediately after delivery in infant, for >6 weeks
- test baby for HIV at 24hrs - and serial testing
- for mom’s who didnt receive antepartum HAART, add nevirapine
DONT breastfeed
less than 1% transmission risk for moms who have undetectable viral loads
HAART = 2NRTIs and NNRTI/protease inhibitor
postpartum depression
begins w/i 2wks - 6 mo delivery
- mood changes, insomnia, phobias, irritability
signs and sx of depression that last <2wks = PP blues, self-limiting
PP depression - may see ambivalence toward newborn
most sig risk factor is prior hx of depression
treatment - SSRIs
- fluoxetine - causes insomnia
- SSRIs can be used safely during lactation
SI with plan - inpt management
lactation
initially colostrum produced –> next 2-3d milk will be produced, after prog and estrogen are cleared
belly-to-belly is required for good latch
–> poor latch –> cracked and bleeding nipples
things that promote breast-feeding - baby on breast within and hour of delivery and unlimited access to baby
how you know the baby is getting adequate milk
- 3-4 stools/24hrs
- 6 wet diapers/24hrs
- weight gain
- sounds of swallowing
how to help with engorgement
- frequent nursing, warm shower/compress to enhance milk flow
- massage breast + hand express
- wearing a good support bra
- use analgesic 20 min before feeding
breast candidiasis - severe discomfort and pain
- antifungal topical - clotrimazole or miconazole
- can add topical antibiotic or mupirocin be S. aureus often co-exists with nipple fissures
- topical steroid crem to faciliate healing
- check baby’s oropharynx and treat baby with oral nystatin then oral fluconazole
best method to suppress lactation - breast binding, ice packs, analgesia
- avoid breast stimulation (–> natural inhibition of prolactin secretion)
bromocriptine associated with HTN, stroke, seizures
OCPs, hormones - associated with thromboembolis, rebound engorgement
thyroid storm in pregnant woman
DONT give I-131 - will accumulate in the fetal thyroid –> congenital hypothryoidism
thyroid storm - propranolol, PTU, sodium iodide, dexamethasone
mortality during pregnancy
pts with pulm HTN - 25-50% risk of death
- similar risk with aortic coarctation with valve involvement or Marfans with valve involvement
mitral valve prolapse
clicking systolic ejection murmur
sxs - anxiety, palpitations, atypical CP, syncope
for symptomatic women - b-blocker
obese mothers
risks - chronic HTN, GDM, preeclampsia, fetal macrosomia, C-section, PP complications
lupus
NSAIDs for athralgias and serositis
severe disease - corticosteroids
hydroxychloroquine - control skin manifestations
breast cancer in pregnant women
breast cancer is more aggressive in younger women
delays of 1-2 mo in clinical workup are common in pregnant women with breast tumors
appendicitus
clinical findings
- fever, N&V, mid-abd pain
- note enlarged uterus shifts the appendix up and out towards the flank
ddx by graded compression US
isoimmunization
amnio, CVS, abortion, ectopic, D/C, abruption, hemorrhage, preeclampsia, C-section, manual removal of placenta, external version
risk = 20%
how to test for fetal anemia - peak systolic velocity in MCA
- invasive techniques include amniocentesis and cordocentesis
fetal hydrops
- develops in the presence of decreased hepatic protein production –> collection of fluid in 2(+) body cavities
- ascites, pericardium, pleural fluid, scalp edema
- can see this on US
- sometimes if extramedullary hematopoiesis is extensive –> HSM
- placentomegaly (placental edema) and polyhydramnios
Lewis antibodies are IgM - DONT cross placenta
bilirubin in amniotic fluid is a sign of hemolysis - spectrophotometric measurements
Liley curve - OD450 deviation v.s. gestational age, tells of hemolytic disease
- zone 3 - means the baby will die in 7-10d –> immediate delivery or fetal tranfusion
- first step in treatment - intravascular transfusion into umbilical vein (otherwise intraperitoneal transfusion)
- maternal plasmapheresis where intrauterine transfusions are not possible
multiple gestations
AFP is doubled in twin pregnancies, fundal height will exceed GA
- other reasons for high AFP = …pilonidal cysts, cystic hygroma, sacrococcygeal teratoma, fetal death
twin death rate is 5x that of singletons
- risk of CP is 5-6x higher
- twins have a higher incidence of IUGR and premature delivery
- how to prevent premies and low birth weight- adequate weight gain in the first 20-24 wks gestation - increased risk of congenital malformations
- MOST concerning complication - premie
fraternal twins signs
- dividing membrane thickness > 2mm
- twin peak (lambda) sign, diff gender, A&P placentas
superfecundation - two ova fertilized separately during the same cycle
identical twins
diamniotic dichorionic placentation - division prior to morula state (3d post fertilization)
diamniotic monochorionic placentation - 4-8d post fertilization
monoamniotic monochorionic - division between d8-12
division at or after 13 d –> conjoined twins
when twin A is breech –> C-section
Factor 5 Leiden
factor V is unable to be inactivated by protein C
associated with stillbirth, preeclampsia, placental abruption, and IUGR
fetal demise - fetal HC wont match with age wont match with bone lengths
advanced maternal age
associated with stillbirth, preeclampsia, gestation DM, IUGR
five stages of grief
denial, anger, bargaining, depression, and acceptance
DABDA
viable pregnancy
yolk sac, appropriate levels of hCG and progesterone - even if there is no heartbeat
- repeat US in 7 days
missed abortion
- CRL > 7mm + no cardiac activity
- medical induction with misoprostol
- methotrexate for ECTOPICs, can be used for intrauterine pregnancies if LMP < 6wks ago
rising rate of C-sections
because VBACs have decreased - due to increased risk of complications (uterine rupture)
also many obs dont perform vaginal breech deliveries or instrumental vaginal deliveries
previous c-sections
risk of placenta accreta
- previous c-sections and low anterior placenta
uterine rupture is a lesser risk
FFP
contains fibrinogen and clotting factors V and VII
cryo - fibrinogen, factor VIII, and vWF
moms who are smokers
placental abruption, placenta previa, FGR, preeclampsia, and infection
bloody show
cervix is extremely vascular and bleeds during DILATION
normal
cervical lesions (during pregnancy)
polyps (soft) v.s. cancer (hard)
- risk factors for cancer are lack of healthcare f/u, smoking hx, etc.
polyps are benign - polypectomy (note colposcopy is to test for cervical dysplasia)
nabothian cysts- doesnt cause bleeding
rape and abuse
age of consent is 16 yo
antibiotic ppx should be offered to all adult rape victims
immediately after rape - samples for evidence, serology/STIs, pregnancy test, emergency contraception, and antibiotics
- at 6 wk f/u - repeat serology for syphilis and HIV (syphilis takes 6wekks to become detectable, 6 mo for HIV)
physical and sexual abuse is associated with chronic - so think in a lady with a new partner and recent onset pelvic pain
intimate partner violence - woman chooses to report this to the police
(child abuse has to be reported)
post menopausal women
estrogen cream - if using longterm, add progestin due to potential systemic absorption concerns
- estrogen is contraindicated with breast cancer ddx
water-based lubricants (NOT pet jelly)
- normally - lubrication during arousal phase is due to transudation across vaginal mucosa from increased blood flow
sexual stimulation promotes blood flow to genitalia … less dyspareunia
oral prog - helps decrease hot flushes
side notes - thin habitus and tamoxifen are associated with lowered estrogen effects
vaginismus
perpetuated by a cycle of anxiety and pain
treatment - vaginal dilators + counseling
note - sensate focus is a therapy indicated for arousal and orgasmic disorder
endometrial cancer
symptomatic cancer
- usu bleeding/spotting
- sometimes discharge
most sig risk factor - obesity
- esp when pt is 50lbs over ideal body weight
- other risk factors - … DM
but an even more sig risk factor is complex atypical hyperplasia –> 29% chance of progressing to invasive cancer
- 30% of women with CAH will have invasive endometrial cancer on final bx
in postmenopausal women - thin endometrium does not exclude risk of non-estrogen dependent endometrial cancer
treat with - hysterectomy + BSO + pelvic and para-aortic lymphadendctomy
- note endometrial ablation is contraindicated in pt with endometrial cancer
breast changes in women
fibrocystic change - associated with cyclic mastalgia
- caffeine intake can increase the pain that is associated with fibrocystic change
breast lump –> FNA (regardless of normal mammo)
- clear fluid and mass resolves –> re-examine in 2 mo
- yields bloody fluid –> excisional bx
- FNA is negative –> excisional bx to rule out false negative result
fibroids
major sx = heavy menstrual bleeding (due to increased surface and vasculature disruption)
submucosal or intracavitary myomas are most likely to interfere with pregnancy - but RARE
- treat with hysteroscopic resection
- exclude other causes of infertility first
fibroids may grow or become symptomatic in pregnancy due to hemorrhagic changes associated with rapid growth = red or carneous degeneration
rarely, fibroids can be located below the fetus –> C-section due to soft tissue dystocia
temporary treatment (3-6 mo) = GnRH agonists
- temporarily reduces sxs and reduces myoma size
- stop treatment - everything returns to persons baseline in 3-4 mo
get embx in women over 40 with irregular bleeding
cervical cancer
greatest risk factor is related to HPV exposure
- so for a pt with a vaginal condyloma - consider that she has been exposed to the high risk HPV types as well
not genetically inherited
if you cant visualize a lesion in the endocervical canal –> conization or co-testing at 12 and 24 mos
- conization (aka with cold-knife or leep) will provide a sample - you can test for invasive cancer
microinvasive cancer - 3mm beyond BM
stage 2 - involvement of parametria
stage 3 - involvement of side wall
concerning path findings
- punctuations and mosaicism = new blood vessels
- atypical vessels - greater angiogenesis
- ectropion (red ring of tissue around ext os) - columnar epithelium that has not undergone squamous metaplasia
- acetowhite changes can indicate dysplasia
pos endocervical curretage –> cervical conization (for further ddx)
- note cryo will not provide you with a sample but can be used to treat dysplasia (after cancer has been ruled out)
side note - HPV can cause oral cancer - bleeding, mass, dysphagia
intraamniotic infection
deliver baby - can vaginally if fetal heart tones are reassuring
low amniotic fluid glucose is the best indication
meds that are contraindicated in pregnancy
Mag sulfate contraindicated in myasthenia
- Mag sulfate works as a tocolytic by competing with Ca entry into cells
terb and ritodrine are contraindicated in diabetics
methylergonovine - ergot, potent smooth muscle constrictor, contraindicated in HTN/preeclampsia
PGF2a (hemabate) - has bronchio-constrictive effect, contraindicated in asthma
b agonists and tocolysis
b-agonists like terbutaline increase cAMP in the cell - decrease free calcium
side effects - tachy, hypotension, anxiety, CP or tightening
terb has been found to not be effective and is dangerous if used for longer than 48 hrs
ROM
vaginal fluid ferning and nitrazine testing
DONT do digital exam in pt with PPROM - risk of introducing bacteria
PPROM - tocolysis may be administered in so steroids can give maximum effect
- risk of chorio with tocolytics beyond 48hrs ROM outweighs benefits of lung maturity
for PPROM - give amp and erythromycin –> prolongs latency period for 5-7d (better than tocolytics), reduces incidence of amnionitis and neonatal sepsis
to prevent - 17-a-hydroxyprogesterone
- give weekly from 16-20 weeks –> 36 weeks gestation
PMS and PMDD
begin in luteal phase, resolve shortly after onset of menses
PMS is milder than PMDD (mood sxs)
- PMS becomes more common as women age
risk factors for PMS - fhx, B6, calcium, or Mg deficiency
- for PMDD - psych hx
treat pain with NSAIDs
treat PMDD with OCPs - suppresses HPA
- SSRIs also work - pts can take the medication only during the luteal phase if they like
PP fever
infection risk is due to mode of delivery
- C-section
- vaginal birth + prolonged labor, prolonged ROM, multiple vaginal examinations, internal fetal monitoring, removal of placenta manually, low socioeconomic status
endometritis - mat tachy and fever
- risk factors - c-section, chorio, GBS pos, prolonged ROM, operative vaginal delivery, prolonged labor, multiple vaginal exams
- polymicrobrial, anaerobes - treat until afebrile for 24hrs, amp/clinda and genta (gram negatives)
- note erythro good for URI, cipro good for g neg and pseudomonas
acute cystitis
- risk is increased with indwelling catheter - ecoli, proteus, kleb, others
mastitis
breast engorgement
lungs - are the most common source of fever on PP day 1
- esp if pt had general anesthesia
- atelectasis may be associated with PP fever
PP wound infection
1) open wound, check for fascial dehiscence, drainage and assessment of fluid
2) packing wound
3) broad spectrum antibiotics for cellulitis or abscess
septic pelvic thrombophlebitis (venous system) - high fever not responsive to antibiotics
- ddx of exclusion
- treat with anticoags, in the short term
confirming gestational age at term
1) fetal heart tones for 30 wks by doppler
2) 36 wks since pos serum or urine HCG
3) 30 US of crown-rump length obtained at 6-12 wks supports gestation of 39 wks
4) US at 13-20 wks confirms gestational age of 39 wks (determined by clinical and physical exam)
crown-rump length will reliably date a pregnancy w/i 5-7 d (in the first trimester?)
if woman presents with discrepancy in size and dates –> pelvic US to confirm dates, exclude multiple gestations, uterine abnormalities, and molar pregnancy
D&C
if you see fatty appearing tissue - that means youre sucking out omentum
- -> laparoscopy will allow closer examination
- -> laparotomy can be used for closer evaluation
operative vaginal delivery
vacuum cup -…risk neonatal jaundice (cephalohematoma?), transient neonatal lateral rectus paralysis
tubal
most likely complication is risk of future pregnancy, <1%
tubal has a protective effect on ovarian cancer incidence
CVS v.s. amnio
CVS - 10-12 wks
- CVS before 10 weeks is associated with an increased risk in rare limb abnormalities
- more likely to involve multiple attempts - failure to obtain adequate sample, requires repeat test later on
- loss rate - 1-3% (NOT related to prior miscarriage)
amnio - after 15 wks
- loss rate - 0.5%
interstitial cystitis
aka bladder pain syndrome
chronic inflammatory condition - urine culture negative but signs of UTI
pelvic pain reported by 70% of women, dyspareunia can also occur
tenderness over anterior vaginal wall
pelvic congestion syndrome
pelvic varicosities
presents with premenstrual or pain during pregnancy
- aggravated by standing, fatigue, coitus
- pelvic fullness or heaviness
- associated sx - vaginal discharge, backache and urinary frequency
nerve entrapment syndrome
following pelvic surgical procedures
- iliohypogastric (groin and pubis), ilioinguinal nerves (groin, pubis, labium, and upper inner thigh) (T12-L1)
- susceptible to injury with low transverse incision
injury to obturator nerve –> inability to abduct thigh
incontinence
overflow incontinence - failure of bladder to empty adequately
- postvoid residual >300 cc (nl is 50-60cc)
- due to underactive detrusor muscle or obstruction (postop, prolapse)
- treat with cholinergic agonists
and intermittent cath
stress incontinence - bladder P > urethral P
- due to urethral hypermobility and/or intrinsic sphincter deficiency
- lifestyle modification, pelvic floor exercise, pessary, pelvic floor surg (urethral sling)
- retropubic urethropexy = best
- for instrinsic sphincter deficiency (so urethral doesnt move)- urethral bulking procedure
overactive detrusor contractions - can override urethral pressure resulting in urine leakage
- lifestyle, bladder training, antimuscarinics
- oxybutynin - anticholinergic properties
mixed - stress and urge
pseudoephedrine - a-adrenergic properties, may improve urethral tone in stress incontinence
- bethanechol for overflow incontinence (neuropathy)
vaginal estrogen has been shown to help in urgency
transvaginal tape can be used for urinary incontinence
risks for pelvic organ prolapse - increasing parity (increased risk with vaginal delivery), increasing age, obesity, CT disorders, chronic constipation, FHx (increases risk 2.5 fold)
- treat uterine prolapse by colpocleisis
- cystolcele by anterior repairs
vulvar neoplasms
BX
vulvar cancer risk factors - HPV, smoking, vulvar dystrophy (lichen sclerosis, specifically the pruritus is an issue), immunocompromised state
lichen simplex chronicus - NON-neoplastic
- topical corticosteroids and antihistamines
lichen sclerosis - treat with steroids –> itch-scratch cycle
–> can progress to squamous cell carcinoma - which would need to be resected (but less than 5%) chance
- extreme vulvar pruritus, dyspareunia,… scarring with loss of architecture, stenosis, resorption of clitoris and labia minora
- can have perianal involvement in figure 8
- premenarchal or postmenopausal
- note SCC is 90% of vulvar cancers
- treat with high-potency steroids - clobestasol
(- disease can be autoimmune related)
pagets disease - plaque-like lesions and poorly demarcated erythema
- with hyperkeratotic overlay
melanoma and high-grade vulvar intraepithelial neoplasia - have a similar appearance
- for VIN3 (white plaques) - superficial local excision + close f/u
Bartholin gland firm mass (esp in postmenopausal woman) = suspicious for malignancy
- fixed nature of the mass
- adenocarcinoma
HPV-related conditions
- condyloma
- vulvar dysplasia
path says cancer –> radical vulvectomy and groin node dissection
would not laser a malignant lesion
- can laser multiple VIN2 lesions
cryotherapy for cervical dysplasia
permanent sterilization
hysteroscopic tubal occlusion (essure) - need back-up contraception for 3 mo –> hysterosalpingogram confirming tubal occlusion
- can be done in office
tubal - but consider pt’s risk for surgery
vasectomy done under local anesthesia
abortion
medical abortion associated with higher blood loss than surgical abortion
- mifepristone (antiprogestin, termination) and misoprostol (PG, induces contractions)
- if heavy bleeding - likely due to retained products of conception –> D&C
manual vaccuum aspiration - < 8 weeks
oxytocin ineffective because those receptors have not been upregulated at early gestational ages
concerned about endometritis - begin abx, then look for retained products of conception (US)
vestibulodynia
idiopathic
treat with TCADs, pelvic floor rehab, biofeedback, topical anesthetics
vulvadynia - treat with estrogen cream and clobetasol
hep b
post-exposure ppx - 7 d after blood contact, 14 d after sexual exposure
- 1 dose HBIG and HBV series
- if source is HBsAG neg or unknown, then only use HBV series
- vaccinated person and responder - no further treatment needed
incubation period for virus is 6 mo
menstrual cycle
starts on day 1 of menses, follicular phase, ovulation, luteal phase
follicular phase - estrogen and progesterone are low –> shedding
- FSH increases - stimulates follicle development
- then FSH decreases - single follicle dominates
ovulation - LH surge (and FSH surge)
- danazol blocks this
- estrogen peaks during surge, progesterone begins to rise
luteal phase - LH and FSH decrease
- ruptured follicle closes and produces progesterone
- estrogen and progesterone thicken lining for implantation
- if egg is not fertilized, follicle degenerates
inhibin - increased in luteal phase
risk to premies
premies - intraventricular hemorrhage, RDS
nipple discharge
concerning d/c - serous, bloody, unilateral, skin changes
benign - guaiac, TSH, prolactin, UPT
cytology for unilateral or guaiac pos d/c
meds - dopamine inhibitors, combined OCPs (stimulate lactotrophs), H-blockers (cimetidine) can inhibit estradiol mechanism…
vaginal cancer
SCC - the usual, posterior vaginal wall
clear cell adenocarcinoma - <20 yo, DES, anterior vaginal wall
clinical features - malodorous vaginal d/c, bleeding, irregular mass/plaque or ulcer on vagina
BX
side note - local metastatic dz to vagina is more common than primary disease
anatomy
ovarian arteries off the aorta
vaginal bleeding
PALM COEIN
polyps, adenomyosis, leiomyomas, malignancy
- endometrial polyp - observation, medical management with progestin, curettage, polypectomy, DONT observe if polyp is > 1.5 cm
coagulopathy (vwf, may show up as menorrhagia), ovarian dysfunction, problems of endometrium, iatrogenic (IUD), other
during pregnancy - viable, ectopic, abortion, subchorionic hemorrhage
- check mat blood type…Rhogam
sexual activity in young women
chlamydia treatment - doxy, re-infection by partner is a cause of recurrent infections
frequent UTIs - postcoital single-dose nitrofurantoin therapy
