OB + Gynecology Flashcards
Time from sperm emission into vagina to cervical canal:
FIVE seconds
No time to wash them out afterwards
Cervical Cap
Fit like diaphragm but smaller
Refit with childbirth or wt gain/loss of 10 lbs
Must stay in place 24-48 hrs, does result in odor
Must be used with spermicide
Diaphragm
Bigger than Cap
Also refit w/children + wt change of 10 lbs
Only has to stay in place 6 hrs post coitus
ORTHO ALL-FLEX is Deb’s Favorite
Must use spermacidal Jelly on inside when placing and insert with more for each act
Natural/Calendar Method
Count backward 14 days from anticipated first day of menstruation to pinpoint ovulation, add 5 days either side.
No Sex from day 10-20
Thermo Method
Chart waking temp BEFORE getting out of bed daily for a few months to pinpoint ovulation then no sex 5 days prior or after.
Better for getting pregnant as this is rather a hassle and you need to stay motivated!
Temperature DROPS during ovulation, then spikes higher than before and stays higher right through menstruation.
Egg White Mucus
Is Fertile
This method can be thrown off by vaginitis, STDs and candidiasis as these make discharge creamy.
Drugs that undermine effectiveness of hormonal birth control
-Dilantin
Anticonvulsants in General (can use Depo, prog only and Gabapentin and Lamotragine are not affected)
- Tetracyclines (This is contested by why risk it?)
- Rifampin (for Tb + Meningitis prophylaxis)
- St John’s Wort
BCP
Take Pill #1 on Sunday after pd begins, this puts you on a nice weekly schedule. No worries about being pregnant during menstruation.
Take pills in the am, after breakfast if they cause nausea. DON’T take at night, you’ll forget more.
Never if Hx of DVT
Never if HX of Factor 5 Leidenfrost
Strong caution in Smokers over 35, notation of risk conversation. Depo Provera (progestin only inj or pills) is safer than estradiol containing BCPs for older smokers. Mirena is prog only or use the copper IUD
Control HTN on meds/lifestyle BEFORE beginning BCP
Not good for DM (esp progesterone only formulas…)
Does a nice job of preventing ovarian cysts as it prevents follicle ripening.
Not for Migraines with neurological sxs
MOST common side effect of hormonal BCP
Break Thru Bleeding
Usually resolves within 3 months
Common NuvaRing side effect
Watery discharge, non-purulent
No ring during menstruation
This functions as does low dose BCP
Hormonal BC that nursing mothers can use
Progesterone Only pills
Depo injections may be approved soon
Depo implantables may be approved soon
Nexplanon
Implantable Progestagin tagged with Barium so you can find it to remove.
Monophasic bcps:
constant dose of hormone(s) throughout cycle. Can be combo or progesterone only
Lo-Ovral Alesse Nordette Ortho-Novo Portia Yasmine Yaz Zovia
There is no evidence that Bi or Triphasics are safer or more effective than are Monos and Monos are much cheaper.
Biphasics
Have two peaks, estradiol early and progestagin late to mimic normal cycle more closely, peaks are just higher than normal so ovulation stays suppressed. Thought is that it does not expose tissue to constant high levels of both hormones during parts of cycle when they are normally decreased.
Aranelle Jenest Mircette Nelova Nircon Ortho - Novum
Tri-phasics
Early estrogen rise, then progestegin, then late estrogen rise most closely mimics natural cycle
Thought to be best for acne control
Anything with Tri in the name
Enpresse
Velivet
Estrostep FE (has iron during menstrual phase)
Natazia
Estradiol Valerate + Dienogest
Quadraphasic BCP
FDA Approved for relief of heavy menstrual periods in addition to bc.
Side Effects of Progestegin BC
Weight Gain Bloating Hirsuitism Moodiness Amenorrhea (more with shot than pills) Breast Tenderness Dizziness Headache
Before giving the IM or Implantable, try the progesterone only pills for a few cycles, to ensure the side effects are manageable to your pt as IM and implantable are more difficult to undo.
Trying to get pregnant after stopping BCP
May happen immediately but…
Higher risk of miscarriage
Safer to use backup during a 3 month washout period, then try.
May be anovulatory after Depo Provera for up to TWO years. Not a good choice for women heading into family situations.
Which cancer do oral bcps reduce if taken more than 10 yrs
Ovarian Cancer
Which Cancer is caused by estrogen only pills
Endometrial cancer is a risk when there is no progestagin to balance the estradiol, at least during the luteal phase, doesn’t have to be present throughout the cycle.
Increase which hormone if you are having breakthrough bleeding
Progestagin
Though break thru may self resolve if it is occurring in the first 3 months. Warn it may occur so as to calm pt when it does.
Mirena + Skyla
Levongestrel Impregnated IUDs
Mirena - 5 years $500
Skyla - 3 years $650
Scant or absent periods are a plus but online it seems like there is a substantial outcry about joint pain, breast tenderness, mood disorders that require SSRIs, lethargy, disinterest in sex, hair loss and WEIGHT GAIN WEIGHT GAIN WEIGHT GAIN
it is a progestagin after all
IUD Basics
PARAGARD: Copper Wrapped - no hormones, Does NOT stop ovulation - works by irritating the uterus so it may cause cramping and heavier periods, Costs about $300.
MiRENA/SKyLA: Progestagin implants, expensive, cause amenorrhea
Inserting is easier in post-gravid females.
Recheck in 1 month to ensure you can find strings. You can trim the strings if the male complains he feels them.
Removal with Sponge Forceps - don’t tug if discomfort, these things implant in the endometrium and may need to be surgically removed. Do a sono if discomfort on tugging or if you cannot find the strings.
Risk of:
PID
Uterine Perforation
Ectopic Pregnancy
Epulsion of IUD
Never insert if Hx of PID, Malignancy, Copper Allergy, Unexplained Vaginal Bleeding (track this down first)
ORTHO-ERVA
PATCH
Monophasic combo
1 Patch /week 3 weeks on/no patch during pd
Always prescribe an emergency patch for pt to keep on file at pharmacy for the inevitable tear off or loss during swimming
Not a good option for swimmers…
Patch on torso, buttocks, arms NOT ON BREAST
Plan B
ELLA
Levongestril
Take w/in 72 hrs of unprotected sex
OTC
or take 1 Lo-Ovral mono phasic STAT then another in 24 hrs
ELLA is prescription and you can take it up to 120 hours post coitus (5 days)
ESSURE
Spring implanted into fallopian Tube to irritate it into scarring shut
Recheck in 3 mo with post-procedure Salpingogram.
Can be undone but thereafter a high ectopic risk
Pharma Abortion
Methotrexate - 90% effective (2 doses) also used for ectopic pregnancy termination. Must have surgical abortion if fails d/t teratogenic effect of methotrexate.
Mifepristone (RU 486) + Prostaglandin E1 (Misoprostol)
A partial progesterone receptor agonist and glucocorticoid antagonist also used experimentally to treat cushigs dz.
-MOST EFFECTIVE Abortion method less
than 7 weeks, use up to 9 weeks in US
Better than aspiration under 7 weeks.
- 600 mg dose in office followed by a
400 mg dose of Misoprostol at home to
encourage contractions.
Can’t give these in primary care, refer to Planned Parenthood or Gyne
Primary Dysmenorrhea vs Secondary
Primary starts soon after Menarche. It’s caused mainly by E2 cutting off the blood supply to the endometrium which causes CRAMPING, necessary to dislodge the sloughing tissue and propel it out through the cervix.
NSAIDS (with proper education as to use) and caffeine are Rx mainstays. Midol contains Tylenol, which doesn’t have any effect on E2 but it does relieve pain - Deb says its not her favorite but I’m not sure we want to interfere with E2’s job, just make it so the resultant pain is more manageable.
Secondary usually affects women over age 25 and is usually caused by Endometriosis.
Role of Prostaglandin E2 in Dysmenorrhea
E2 is released in response to the breakdown of endometrial tissue at the end of the Luteal phase, when the corpus runs of of progesterone to support it and a placenta has not formed to take over progesterone production.
E2 constricts the blood supply to the endometrium, worsening the situation there and killing off more cells. As they die of hypoxia, they are sloughed from the mesometrium and the irritable, hypoxic uterus cramps, propelling the slough out the cervix.
Ischemia Hurts. It hurts in the heart, it hurts in the muscles after a work out and it hurts in the uterus. We call it Cramps.
Leiomyoma
Fibroids
Noncancerous MYOMETRIAL (muscle) growths that often appear during middle to late child bearing years causing either no symptoms or painful protracted menses and low back ache. Fibroids are a main reason for hysterectomy in this age group. They “retreat” after Menopause.
They are round and can grow as large as a grapefruit - these can be felt through the abdominal wall, of course.
Unfortunately, they do not stay IN the uterus and can grow outside it (subserosal), into its muscular walls (submucosal + intramural) and even in the broad ligament between the uterus and ovaries. It can also pedunculate from the cervix into the vagina (in statu nascendi)
They do not become malignant. There ARE malignant fibroid like tumors of the uterus but they do not develop FROM the benign fibroids and having benign fibroids is not a risk for malignancy. Malignant tumors are present AFTER menopause.
They do, however become life threats when they grow elsewhere in the gut, strangling the intestines. This used to be rare but is seen with increasing frequency and is thought to arise from a laparoscopic hysterectomy technique employing a MORCELLATOR which chops the uterus up into bits inside the abdominal cavity then extracts the bits (obviously not ALL of them) out through the small incision. It may not be a good idea to liberate this uterine tissue into the abdominal cavity like that when it clearly has the ability to colonize other tissues.
African American decent is the biggest fibroid risk in the US with an estimated 80% of women developing fibroids by their 40s - not all are problematic. OBESITY, its related comorbidities and diet high in red meat (hormones or fat?)
Endometriosis
Growth of endometrial tissue outside the uterus, usually on the outside of the uterus, the ovaries or tubes but it can migrate far. It is thought to escape the uterus during menstruation via the fallopian tubes (retrograde menstruation). There are more developmental theories though.
The immune system ought to snap these bits up and dispose of them but if it is compromised, it may not. Also, there has been a huge reduction in “menstrual rest” since women no longer spend decades pregnant and that is thought to have increased the incidence of escaped endometrial tissue.
The problem is that, wherever it is, endometrial tissue behaves as if its in the uterus and it BLEEDS/sloughs in response to the monthly cycle.
Blood is an irritant whenever its is outside its vessels and this causes inflammation, E2 is released to deal with it all and severe cramping results
Cramping can involve the low back and often radiates to the legs.
Endometriosis is associated with Ovarian Cancer, Brain Cancer and Non-Hodgkins Lymphoma. Interestingly, it is NOT associated with endometrial cancer.
Family Hx is the main risk but Dioxin exposure has also been implicated
YOU CANNOT SEE ENDOMETRIOSIS ON SONOGRAM. YOU MUST DO A LAPAROSCOPIC INVESTIGATION AND BIOPSY THE TISSUE.
PROGESTERONE inhibits endometrial growth and so progestagin therapy is an option for management. Other Estrogen Blockers are employed.
This is an old disorder, not new. Hippocrates was prescribing early marriage and child bearing to women ages ago so as to resolve maladies of the uterus. Indeed VAGINAL (not c-section) Childbirth reduces recurrence (perhaps by widening the cervical opening and making it the easier way out?)
Unfortunately, infertility does result from endometriosis.
Adenomyosis
Endometrial growth INTO the Myometrium
Imaging of choice in the pelvis?
Sonogram
Sonos for all dysmenorrhea in sexually active females. You can ID:
Pregnancy Ectopic Ovarian Cyst Torsion Fibroids
You CANNOT see ENDOMETRIOSIS on Sono
Dysmenorrhea?
Pelvic Exam
Tender? RX for PID
Didn’t resolve pain?
Sono
Find something on Sono?
Laparoscopy + Biopsy to ID tissue
Rx for PID is EMPIRIC
Cover all the likely stds:
250mg of Cephtriaxone IM
1mg of Axithromycin PO in office
Send her out the door with a 10 day supply of Doxy 100mg BID for syphillis and whatever else might be in there.
Debs fav Meds for PMS
Fluoxitine days 16/18- Menstruation
Now FDA approved (SaraFem)
B6, 100 mg daily
Mg, 200-360 mg daily
You may be able to back off the SaraFem once the vitamin regimen is well underway.
If this doesn’t work, work up for major depressive disorder, might need SSRIs all month? OR…. check their hormone levels and consider bioid progesterone therapy…
PMDD
Premenstrual Dysphoric Disorder
PMS on steroids… Especially last two days before menstruation.
Monophasic BC (Yaz or Effexor)
Check hormone levels and consider progesterone
Consider Fluoxitine daily?
This is in the DSMIV
Major risk of bipolar disorder
Most common causes of Ectopic Pregnancy
Adhesions + Endometriosis
Kehr Sign
Shoulder Pain from Blood, Gas or other irritant in the Peritoneal Cavity.
Worse when lying down with legs raised and that spreads the blood/irritant around and manages to really irritate the phrenic nerve, hence the shoulder pain.
With ectopic, the irritant is blood, possibly lots, that’s why they pass out..
Left Shoulder Kehr is classic for ruptured spleen
Menstruating woman comes in with pelvic pain and/or spotting, what to do (in order)
Pregnancy Test (dip stick in office) and clean catch for
Qualitative b-HCG serum test
Anything over 1500 should show up on a pelvic
Ultra Sound. If it doesn’t show, and there’s
pain/spottig its ectopic untilproven to have implanted
appropriately
Transvaginal or Pelvic Ultrasound looking for mass in the
tubes and uterus and elsewhere (could be outside
in the peritoneal cavity!)
When to use Methotrexate in OB
Ectopic pregnancy where b-HCG less than 5000
Over 5000 the fetus is too big and could
cause a rupture before methotrexate works.
Ectopic Mass on sono is less than 3.5 cm - anything larger
is an imminent rupture risk.
No Kidney or Liver Dz - these contraindicate Methotr.
Pt is Hemodynamically Stable - If Bp + HR are at all
unstable, surgically remove the ectopic
Methotrexate takes a while to work but serial b-HCGs should drop by 25% within 7 days of administration IF its working. If it isn’t, give it again, check b-HCG and re-administer up to 3X. If b-HCG doesn’t fall after the third time, surgery is indicated.
Even if it works, Methotrexate takes months to complete and you have to keep having the patient come back for b-HCGs until she’s back to baseline (5 Units/mL). Still, Methotrexate carries no risk of causing adhesions and is thus preferable to surgery if the patient is suitable.
Fertilized Ovum that never progresses to a Zygote or beyond
Blighted Ovum
50% of all miscarriages that are not d/t chromosomal anomaly are blighted ova. The mother may not even be aware of these miscarriages as they would be flushed with the normal period or perhaps just a little late.
%age of all pregnancies that miscarry
15-20% !!!
Miscarriage is common, very. 50% are d/t chromosomal anomaly. Half the remainder are Blighted Ova and the remaining 25% have mixed etiologies but Progesterone deficiency is a big one.
If progesterone does not rise with HCG the pregnancy cannot be sustained even if there is no chromosomal anomaly so, if you patient wants to be pregnant and is spotting in the 1st trimester, along with her quantitative HCG, get her Progesterone levels. If its low for the gestational age, supplement with transvaginal Progesterone suppositories.
Of course supporting a genetically doomed pregnancy with progesterone may be a bad idea but that is a call for the specialists in OB, not you in PC. Put her on the progesterone (DMII may be a contraindication) and refer her. They will test the chromosomes and decide whether or not to continue to support the pregnancy.
Miscarriage and the Cervix - significance?
If the cervix is closed and there is spotting, the pregnancy may be saved by bed rest and progesterone suppositories.
If the cervix is open, the pregnancy is doomed
If its open and the “Products of Conception” are visible, the miscarriage is either complete or partial (underway). Send the “product” to the lab and schedule a Sono to ensure no “bits” remain to cause infection. Follow your pt’s b-HCG until its back to normal (5 U/mL)
If its only partially complete, the pt needs a D+C to clear the product from the womb.
What if Mom tests Rh(-) at her first prenatal screen?
Give her Rho-Gam at 28 weeks and whenever you do an invasive intervention like amniocentesis that might mix fetal blood cells with maternal cells and then dose her again within 3 days of birth.
This will protect the next Rh(+) baby from being attacked by mom’s antibodies.
Chadwicks Sign
Bluish Vulva/Cervix of Pregnancy
Also a BOGGY UTERUS is a physical sign on exam of early pregnancy.
Molar Pregnancy/ Gestational Trophoblastic Dz
An abnormal situation in which an unfertilized egg implants in the endometrium and grows.
Complete Mole: An egg with no maternal DNA is fertilized by 1-2 sperm and implants into the uterine lining and begins to grow. It can’t become a fetus but it knows enough to divide and grows into a mass. 20% of Complete Mole Pregnancies just keep growing, becoming aggressively malignant.
These look like clusters of grapes or a Snow Storm Pattern on Sonogram
Partial Moles: These usually have 3 complete sets of DNA. The mothers and two sets of the father’s DNA, either from two sperm or d/t the father’s DNA spontaneously duplicating on entering into the egg. Partial Moles may in fact result in a fetus growing in the uterus with the tumor. There is the potential for malignancy.
It could also just be a missed miscarriage where the pregnancy became non-viable but just wasn’t expelled. these don’t continue to grow.
You can spot this because the b-HCG on these goes wild, much higher than it is supposed to be. Also the Malignant Completes metastasize
If not metastatic, D+C is the Rx. If b-HCG doesn’t plummet after D+C, STAT Hysterectomy is in order to prevent metastasis
Clusters of Grapes/ Snow Storm Pattern on pelvic Sono
Molar Pregnancy
Look for uterus bigger than expected for gestational age and b-HCG higher than expected for gestational age
How do we screen for Gestational Diabetes?
Fasting BG of over 126
Random BG of over 200
A1C of over 7
Glucose Tolerance of over 140
Gestational Diabetes predisposes the mother to DMT2 later in life but for the fetus, the risks are the same as for being born to a woman who had diabetes before becoming pregnant
What are the risks to the Fetus of women with Gestational Diabetes and/or Diabetes prior to pregnancy?
Hypoglycemia @ birth - Fetuses of diabetic mothers are
constantly exposed to high sugars. This causes them to up regulate Insulin production and down regulate Glucagon. This results in baby being able to process all that sugar while in utero but leads to underdevelopment of the response to low blood sugar (because the fetus never encounters this phenomenon) so its alpha cells and liver do not produce and store Glucagon for a crisis and, a sugar crisis (in the form of birth) is coming. When normal babies are born and cut off from Mom’s blood sugar supply, their own glucagon levels skyrocket and stay high until colostrum or formula is taken in. When babies of diabetic women are born, not only is there is no glucagon peak but they have learned to maintain an abnormally high insulin level in utero - No sugar source, no glucagon and extra insulin add up to hypoglycemia pretty fast - its a 911 if not planned for in advance and addressed immediately at birth. Diabetes makes a pregnancy high risk for mom (pre-eclampsia and later DMT2) and for baby…
Mom’s RBCs are all hyperglycosylated (bound to sugar) and sugared up Hb doesn’t carry O2 very well, risking hypoxia (and brain damage) in baby. Baby adapts by making more RBCs so each scrap of O2 can be snagged. All well and good but extra RBCs clog up the works and bump into each other and become raggy. They get broken down in the brand new spleen and suddenly the little hepatic system os overwhelmed with breakdown products of RBCs and the baby is jaundiced even before birth just for having too much bilirubin for his liver to process, even if his liver is mature it just can’t handle that much.
Macrosomia
Baby over 8lbs 12 ounces
Babies of Diabetic women have a significantly increased risk of ARDS, what’s the connection?
Fetal Insulin blocks the production of surfactant in fetal lung tissue.
In a normal baby late in development the adrenals come online and secrete enough cortisol to oppose insulin’s suppression of surfactant synthesis in the lung. Surfactant is made and the baby is born ready to breathe.
In the fetus of a diabetic woman, there is so so much insulin in play in order to manage the mother’s high BG that the baby’s adrenals cannot produce ENOUGH cortisol to overcome insulin’s effect in the lung and surfactant continues to be suppressed even to full term. Thus is a full term macrocosmic baby of a diabetic woman similar to a preterm baby - no surfactant, not ready to breathe at birth, high risk of Acute Respiratory Syndrome.
For this reason, the surfactant level of a diabetic woman’s fetus needs to be followed in late pregnancy and she must be treated with betamethasone if surfactant isn’t online by 38 weeks.
The stress of compression through the birth canal typically causes a burst of cortisol from a normal baby’s adrenals which in turn produces a surge in surfactant just as baby is being born and getting ready to scream. A C-Section baby, diabetes or not, doesn’t get that surge of surfactant and is less ready to breathe than a vaginally delivered baby. A diabetic C-Section baby has two strikes against him in the respiration department at birth in that hyperinsulemia reduced his surfactant production before birth and C-Section delivery side-stepped his cortisol/surfactant surge from delivery compression.
Hyaline Membrane Dz
No surfactant at birth, risk of ARDS
Treat with betamethasone
DM and Shoulder Dystonia
Bigger babies have bigger shoulders
If they get stuck in a vaginal birth, the OB may have to break the clavicle(s) to get those shoulder(s) through.
If they opt for C-Section to avoid that, there is still the problem of not being squeezed in the birth canal and missing out on the cortisol/surfactant surge that creates.
Don’t be hyperglycemic during pregnancy
What about the hearts of babies of Diabetic women?
They have a surprisingly high risk of cardiomegaly and heart failure as well as The most frequent cardiac anomalies in IDMs include ventricular septal defect, transposition of great arteries and aortic stenosis. Defects involving the great arteries, including truncus arteriosus and double outlet right ventricle, are also more prevalent in IDMs
Neonatal Echocardiography and septal thickness measurement is in order for fetuses of Diabetic Women
Premature Birth
Premature Labor
Before 36/37 weeks actual cut off is disputed
Labor before 36 weeks WITH:
- Dilation and/or - Effacement
If there is bloody/watery discharge test it to confirm it’s
Amniotic Fluid and, if it is, watch maternal temp for infection
Prematurity and Cerebral Palsy
50% of babies born with CP are premature
So many things increase risk of even a normal infant sustaining brain damage before or during birth that could result in cerebral palsy but premature birth is a solid risk.
Asphyxia during after or prior to birth is the other big risk
-Maternal Shock + Hemorrhage
- Placental Complications (Abruptio, Previa, Prolapse)
Infection/Inflammation - may increase oxygen demands
that, if unmet, lead to brain damage. Specific bugs:
-rubella – German measles
-toxoplasmosis – infection caused by parasite
-herpes – sexually transmitted disease
-chorioamnionitis – inflammation of fetal membranes
due to bacterial infection
Low Birth Weight
Less than 5 lbs 8 ounces or 2500 grams
fFN
Fetal Fibronectin
This is a sticky protein that is normally present in amniotic fluid early and in the last two weeks of pregnancy. It should not be there between.
Its presence is 95% accurate for delivery within 2 weeks
If you find it before 36 weeks, give the woman MgSO4 and/or Terbutaline (B2 Antagonist) to slow onset of labor and begin treating with IV Betamethasone to ripen the lung tissue into producing surfactant in anticipation of an early delivery.
Whiff Test +
Thin White Grey discharge
Itchy/burn
Clue Cells on wet mount
Bacterial Vaginosis d/t Gardnerella
Give Metronidazole, 500 mg BID 7-10 days
if drinkers, give Clindamycin Cream or MetroGel
Affirm Test
Triple Screen for:
Yeast
BV
Trich
Quadruple Test
Tests for Genetic Anomalies in pregnancy
mainly Trisomy anomalies
These drugs stave off labor
MgSO4 (Ca channel blockade somehow)
Terbutaline (Beta 2 Antagonist)
Nifedapine (CCB)
PROM
Premature Rupture of Membranes
Main cause of premature birth
If over 36 weeks, induce labor within 24 hrs
If under 36 weeks: Stave off labor and ripen lungs
Keep mom in bed, Trendelenberg if necessary while you give IV steroids and monitor maternal temp for fever, giving IV ABX if it appears.
Give MgSO4/Terbutaline/Nifedapine to stave off active labor while the steroids work on the lungs.
Ferning
The appearance of dried amniotic fluid on a glass slide under the microscope
Nitrazine Test
For Amniotic Fluid in Vaginal Secretions:
If Yellow, no Amniotic Fluid present
If Blue, Amniotic Fluid is present
HTN (over 140/90)
Edema
Proteinuria
Preeclampsia
Rx is Methyl Dopa for HTN 250-500mg BID PO
Trial of labor may cause Bp to skyrocket so these women get sectioned in a facility with a NICU
Test the proteinuria with micro albumin test, much more sensitive
Most common in nulliparous women under 17 and over 35
HELLP
H-Hemolysis E-Elevated L-Liver Enzymes L-Low P-Platelets
HELLP is a complication of Preeclampsia.
Suspect it if: Epigastric or RUQ pain N/V Signs of Preeclampsia (HTN, Edema, Proteiuria) Pulmonary Edema
This is serious business so if that baby is over 34 weeks, get ready to deliver it C-Section. See if you can control symptoms with MgSO4/Nifedapine/Terbutaline long enough to get enough steroids in to ripen those lungs but get ready for an emergency C-Section
HPV Cervical Cancer
Warts
16, 18 (guardisil) 31,33,45
6 + 11 (guardisil)
PCR Test
Polymerase chain Rxn
Chlamydia
GC
Better than bacterial culture
CA 125
BLOOD MARKER FOR OVARIAN CANCER
mildly elevated in all gyne inflammation
Best Syphilis Tests
Non-Treponal Antibody Test - Initial Syphilis Screen - Highly Sensitive but Non-Specific for syphilis, have to do RPR if +. This tests for Antibodies that will disappear 3 or so years after syphilis is successfully treated, so it can be used to dx a second case of syphilis
Treponal Antibody Test is highly specific for syphilis but tests for IgG Antibodies, which will remain for life after someone is cured of syphilis, this test cannot be used to dx a second case of syphilis after the first is cured. It CAN dx the first case.
RPR - Rapid Plasma Reagent for confirmation when Non-Treponal Antibody Screen is (+) and to monitor the effectiveness of syphilis treatment by serial AB measurements.
VDRL on CSF for NeuroSyphilis
Treponema Pallidum
The SYPHILIS spirochete, ugly cousin of the Borrelia Burgdorfi spirochete of Lymes disease. Both can get into the CSF
Uterine Atony
Inability to contract.
The main cause of postpartum bleeding
Oxy during labor can cause it MgSO4 can do it Retained Placenta HUGE baby FULL bladder MANY pregnancies (full term - stretching) Lots more...
Rx for Post Partum Bleeding is UTERINE MASSAGE and PITOCIN IM/IV. If that doesn’t work, give a prostaglandin (METHYLPROSTAGLANDIN) but not to Asthmatics as it will cause smooth muscle contraction in the bronchioles as well.
Placenta Accreta, Increta, Percreta
Retained Placenta: Normally the placenta adheres to the base membrane of the uterine lining, the ENDOmetrium
Accreta: Placenta is firmly attached to the MYOmetrium but has not grown INTO the muscular layer. Often d/t uterine scar: prior C-Section or prior D+C 75% of retained placentae are Accreta.
If diagnosed before birth, C-Section with D+C or
hysterectomy are the Rx
Increta: The placenta grows INTO the Myometrium 20%
Again, C-Section but need for hysterectomy increases
Percreta: The placenta grows THROUGH the MYOmetrium and through the SEROSA, the Uterine Covering.
This requires hysterectomy
Ultrasound in the 2nd/3rd trimesters makes the DX and differentiates between severities. MRI can help if Ultrasound is vague.
Cervical Motion Tenderness means what and is also known as?…
Means likely PID
AKA: Chandelier Sign
MucoPurulent Discharge also Likely
Test for Gonorrhea, Chlamydia
Rx: 250mg Cephtriaxone IM in the office and 10-14 days of Doxy 100mg BID. We were trained 1mg Azithromycin (4 250mg tabs in the office at that visit) but that’s more for males. In contrast to Chlamydia Urethritis in males, PID in women is a DEEP infection and we really need good penetration. Plus Doxy will also cover Syphilis, which she could have an not yet know.
Most common cause of Fallopian Tube scarring
STDs, most particularly CHLAMYDIA
WHAT happens when PID spreads into the abdomen?
And what do we call that?
What happens?? Chlamydia and/or Gonorrhea inflame the liver capsule and adhesions form between it and the parietal peritoneum.
We call it FITZ-HUGH-CURTIS Syndrome
It presents rather like cholecystitis in that it is RUQ pain that may radiate to the left shoulder but timing is wrong in that it has no relation to eating. Deep breaths, coughing and laughing aggravate. It presents essentially as RUQ pleuritic pain.
Ultrasound is usually inconclusive, unless there are incident gallstones, which may misdirect the DDX and result in surgery. At least if this does happen, the liver/peritoneal adhesions may be seen.
Cervical testing for Chlamydia (5X more likely) and Gonorrhea confirm the Dx and the usual treatment is administered for PID. If the Dx was made without actually trying to take out the GB and antibiotics don’t fix the pain, endoscopic surgery can release the adhesions.
Blood Changes In Pregnancy:
VOLUME: Plasma and RBCs increase but plasma increases more. Overall volume increase is 30-40% or around a 2L increase (normal being 4.5 - 5.5 L). It is diluted though so Hb usually drops to around 10.5 from normal of around 14.
HCT/Hb drops from 42/14 to 34/10.4
WBC increases from 4-10.5 to 5-20 as there’s lots more to be tickling the immune system
RBCs stay the same, that’s why the volume increase is dilution. Its also why some pregnant women become less exercise intolerant (that and a huge belly and back strain…)
COAGULATION FACTORS increase with the increased plasma including Fibrinogen.
No Uterus or missing/shortened vagina?
Mullerian Dysgenesis or Agenesis
46,XX (normal chromosome number) but there is a genetic substitution that causes the uterus cervix and vagina to be affected - the patient is otherwise normal and has ovaries so they do enter into puberty but no menstruation. It is the cause of 15% of primary amenorrhea cases.
Rx is surgical vagina. Procreation possible via removal of eggs surgically and surrogacy.
Syndrome of 45, XO
Turner Syndrome
Webbed Neck
Small Stature
Low estrogen due to genetically depleted primordial follicles
Syndrome of prior uterine surgeries causing adhesions and placental abnormalities
Asherman’s syndrome
Hormone Lab Findings in Primary Amenrrhea
Low estradiol
Increased FSH
Increased LH
The message is being sent but Ovaries are Not responding.
Interestingly, this is the same in MENOPAUSE
MEMBRANES RUPTURE EARLY, WHAT TO DO???
PROM - Premature Rupture of Membranes
34 is the Magic Week…
Before 34 weeks: Save the pregnancy if you can. Admin Corticosteriods to mature the alveoli and IV Amox or Ampicillin to forestall infection.
After 34 weeks, proceed to delivery either by induction or C-Section
Tocolysis (pharmaceutical suppression of labor) is not recommended. Terbutaline (B2 agonism), Nifedipine (peripheral Ca++ blocker relaxes smooth muscle) and/or MgSO4 are not recommended for PROM
HOW do you tell it’s amniotic fluid and not pee or increased Vaginal Secretion?
pH: Use Nitrazine Paper!!!
Amniotic Fl is usually a bit basic pH7-7.5 whereas Vaginal Secretions should be acidic 4.5 - 5.5. Pee is usually 5 but should not be in the Vagina from which you will retrieve your sample. NITRAZINE paper is YELLOW at pH 5 (normal vaginal secretions) and turns OLIVE as pH moves on toward 6. Beyond pH 6 it becomes increasingly GREEN-BLUE, turning BLUE-Grey at pH7. By pH 7.5, which would be taken as pure amniotic fluid, the paper would be DEEP BLUE.
FERNING: amniotic fluid ferns on a slide when dry, lots of protein.
Galactorrhea in non-pregnant female. What to do?
Think PITUITARY ADENOMA
Test SERUM PROLACTIN - You’ll need support to MRI
If Prolactin is Elevated, you can MRI the Pituitary.
If there is an ademona (more specifically a PROLACTINOMA), BROMOCRIPTINE is the drug of choice
Dopamine normally inhibits Prolactin and Bromocriptine is a Dopamine Agonist
Prolactin reigns in normal lactation when the body is invested in not getting pregnant. Prolactin suppresses estrogen so follicles do not develop. It also suppresses Testosterone. Sex drive may decrease, vaginal dryness may cause painful intercourse and osteoporosis is a risk.
