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
