OBGYN Flashcards
Primary Amenorrhea
No Menses by age 13 with no secondary sexual characteristics
or
No menses by 15 with normal growth and secondary sex characteristics
Secondary Amenorrhea
Previous menstrual cycle but now absent for 3 cycles or 6 months
Pregnancy, Weight changes, Hypothyroid, Prolactinoma, drug use, exercise, etc
Endometrial atrophy (Asherman’s syndrome)
Pituitary Dysfunction (Sheehan’s Syndrome)
Premature ovarian failure (FSH >40)
Dx: HCG, FSH, PRL, Thyroid panel, Estrogen ,progesterone
TX: OCP if don’t want to be pregnant
Cyclic progesterone 10mg for 10 days if want to get pregnant
Physiologic Amenorrhea
Seen prepubescently, During pregnancy and post menopause
Most common cause of secondary amenorrhea
Pregnancy
Genetic reasons for Primary Amenorrhea
Turners Syndrome
Hypothalamic Pituitary insufficiency
Androgen insensitivity
Anorexia
Mullerian agenesis
Imperforate Hymen
Dysmenorrhea
Uterine pain at time of Menses (primary or secondary)
Painful Menstruation that affects Daily Activities
Primary - Due to increased prostaglandins
Secondary - Due to pelvic uterus pathology
Recurrent Crampy Midline Lower Abdominal pain 1-2 days before menses starts
Lasts 12-72 hours
Normal exam
Tx: Supportive care, heat etc,
NSAIDS and hormone therapy
Laparoscopy
Dysfunctional uterine Bleeding (Abnormal Uterine Bleeding)
Unexplained bleeding in nonpregnant women
Normal Exam
No specific test - HCG, H&H, etc.
Endometrial biopsy to rule out cancer in >35 with obesity, hypertension or DM
Biopsy for all postmenopausal women
Causes = PALM COEIN
Acute hemorrhage = IV high dose estrogen or high dose OCP
Chronic management = Estrogen progestin OCP First line
Progesterone if Estrogen is contraindicated
Levonorgestrel IUD
NSAIDS if hormones are unwanted
Surgery (hysterectomy is definitive), Can do endometrial ablation
PALM COEIN
Polyp
Adenomyosis
Leiomyoma
Malignancy or hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Classified
Menopause
Cessation of Menses over 12 months
FSH >30 (not necessary for diagnosis)
Over 40 with no pathologic cause
If under 40 (Premature ovarian failure)
Average 51 years
Hot flashes, Night Sweats, dyspareunia, vaginal dryness Classic symptoms
Tx:
If uterus = HRT (Estrogen+ Progesterone)
If No uterus = Estrogen
HRT can cause increased risk of MI, DVT, CVD, Breast Cx, increased TGL
Unopposed estrogen Risk
Endometrial cancer
Normal Cycle Physiology Phases
2 phases
Follicular Phase (proliferative)
Day 0 to day 14
Luteal Phase (Secretory)
day 15 to day 28
Normal Physiology Phases
Follicular Phase
First part of menstrual cycle, day 0 - day 15
First, GNRH (from hypothalamus) stimulates FSH and LH release (anterior pituitary)
A follicle grows, secreting estrogen
Estrogen initially gives negative feedback
Once estrogen levels are high enough from follicle secretion, it begins to give positive feedback on FSH and LH which then surge
Estrogen secretion is increased even more from the follicle,
It induces an LH spike which causes ovulation
Normal Physiology Phases
Luteal Phase
Typically the luteal phase is days 15-28 of the cycle
After ovulation, the follicle becomes the corpus luteum which secrets progesterone and provides negative feedback to FSH and LH
If pregnancy does not occur, the corpus albicans is formed which no longer secretes estrogen or progesterone.
This decrease in hormones leads to endometrial sloughing or menses
To begin a new follicular phase of the menstrual cycle, GNRH is secreted and cycle restarts
Normal Physiology of Menstrual cycle
Average 28 day cycle
Can be from 20-35 days
2 phases (Follicular and Luteal)
Cycle begins on first day of bleeding (Menstruation) (day one of cycle)
Ovulation or release of the oocyte from ovary begins 14 days before first menstruation (day 14 of average cycle)
Fertilization chance is highest between day 11 and 15 of average cycle
Premenstrual Dysphoric Disorder
Repeated episodes of significant depression and similar symptoms in the week before menstruation
(Occur during Luteal Phase and resolve with menstruation)
Tx SSRI (Fluoxetine, Sertraline)
Can be use symptomatically or regularly
Others: Benzos, TCAs, Clomipramine, Birth Control, Diuretics, Low dose estrogen, GNRH
Ovariectomy for severe refractory cases
Premenstrual Syndrome
Caused by an imbalance of estrogen and progesterone along with excess prostaglandin production
1-2 weeks before menses (Luteal Phase)
Resolve with menses
Bloating, breast tenderness, HA, edema,
irritability,Depression, Anger, Anxiety, Social withdrawal, Confusion (disruption in function)
Tx: Exercise and stress reduction are beneficial
decrease caffeine, NSAIDS
SSRI are first Line
Combined OCP
GNRH agonist
Surgery (bilateral oophorectomy/salpingo oophorectomy is last resort
does not hinder life
Cervicitis
Infection of the cervix, usually from STD.
Inflammation of Cervix from Allergy, spermicide or chemical exposure
Gonorrhea
Chlamydia
Herpes Simplex
Human Papillomavirus (HPV)
Trichomoniasis
Tx:
Infection: Proper ABX
Inflammation: remove offending agent
Gonorrhea
N
Lactational Masitis
First line is NSAIDS (Ibuprofen)
Continue breast feeding
Cool Compress
If not improvement ABX (dicloxacillin or cephalexin)
Consider MRSA coverage (Bactrim, Clinda, Vanco)
PCOS US
String of pearls
Polycystic Ovary Syndrome (PCOS)
Amenorrhea, obesity or overweight, hirsutism
PE will show bilateral ovarian enlargement, acanthosis nigricans
Labs will show high LH to FSH, androgen excess
Most commonly caused by insulin resistance
Treatment is combination oral contraceptive pills, lifestyle
changes, metformin
Most common cause of infertility
Endometriosis
Patient presents with pre- or mid-cycle dysmenorrhea, dyspareunia, dyschezia (painful bowel movement)
PE may show uterosacral nodularity or a fixed or retroverted uterus or adnexal mass
Definitive diagnosis is made by laparoscopy
Most common site is ovaries
Tx: NSAIDs, COCs, depot medroxyprogesterone acetate, GnRH agonists, surgery
Preeclampsia Severe features
Systolic over 160
Diastolic over 110
Platelet under 100,000
Serum Creatinine over 1.1
LFTS twice normal
RUQ or Epigastric pain
Refractory Headache
Neuro symptoms (vision, hearing etc.)
Screening Glucose tolerance test
Diagnostic criteria for the 100-gram three-hour GTT to diagnose gestational diabetes:
100-gram oral glucose load is given in the morning to a patient who has fasted overnight for at least 8 hours.
Glucose concentration greater than or equal
to these values at two or more time points is generally considered a positive test
100 gram load
Fasting 95
1 hour 180
2 hour 155
3 hour 140
Follow up Glucose Tolerance test
Obtain a random glucose on all pregnant women during the first prenatal visit to check for preexisting diabetes, then conduct a repeat screening at 24-28 weeks
**Screening consists of administering a nonfasting 50-g glucose challenge test, followed by a serum glucose level 1 hour later. If the 1-hour serum glucose = > 130,
- Fasting: 95
- One hour > 180
- Two hour > 155
- Three hour > 140
Gestational Diabetes Mellitus
Screening between 24 and 28 weeks with 50 g glucose load (abnormal: glucose > 130–140 mg/dL after 1 hr)
- Diagnostic criteria
- A 100 g glucose challenge with > 95 mg/dL fasting, > 180 mg/dL at 1 hour, > 155 mg/dL at 2 hours, or > 140 mg/dL at 3 hours
- > 130–140 mg/dL after 1 hour challenge can be positive depending on facility and local prevalence
- Rx: lifestyle changes, fetal growth monitoring, insulin
- Fetal risks: macrosomia, respiratory distress syndrome, neonatal hypoglycemia
- ↑ maternal risk of type 2 DM
Cervical Cancer Risk Factors
HPV
HIV
Immunosuppression
Smoking
Young age intercourse <18
Multiple sex partners
High risk partners (HPV)
Multiparity
Long term OCP use
history of chlamydia
Family history of cervical cancer
Uterine Fibroids (Leiomyoma)
Common during reproductive-ages
Menorrhagia and dysmenorrhea
PE will show a enlarged, asymmetric, and nontender uterus
Diagnosis is made by pelvic ultrasound
Majority do not require surgical or medical treatment
Severe cases: myomectomy (fertility can be preserved) or hysterectomy
Cystocele
refers to a prolapse of the posterior bladder into the anterior vagina
Risk factors for cystocele include pregnancy, vaginal delivery, advanced age, obesity, multiparity, menopause, and diabetes mellitus.
Funnel-shaped bladder.
Additional testing that may be needed includes the cotton swab test, voiding cystourethrogram, and cystometrogram.
Treatment of a cystocele consists of conservative management (weight reduction, pelvic floor and Kegel exercises, pessaries) and surgical interventions (anterior vaginal colporrhaphy, tension-free vaginal tape procedure).
Uterine Prolapse
Stage 1 is characterized by a pelvic organ that is > 1 cm above the hymen.
Stage 2 is characterized by a pelvic organ extending from 1 cm above to 1 cm below the hymen.
Stage 3 is characterized by a pelvic organ located > 1 cm past the hymen without complete uterine prolapse.
Stage 4 is characterized by complete uterine prolapse.
Lifestyle modifications that decrease the risk of uterine prolapse include weight loss if overweight, fiber-rich diet, avoidance of heavy lifting or straining, smoking cessation, and Kegel exercises to strengthen the pelvic floor muscles.
Treatment for uterine prolapse includes lifestyle changes, pessary placement, and hysterectomy.
Uterine Prolapse Risk Factors
Risk factors:
multiparity, age, decreasing estrogen levels, trauma
Tx:
Kegel exercises, pessary, surgery
Gestational Diabetes complications for Fetus
Macrosomia
RDS
Neonate Jaundice
Neonate Hypoglycemia
polycythemia
hypocalcemia
hypomagnesium
polyhydramnios
shoulder dystocia
Gestational Diabetes complications for Mother
Preeclampsia
Birth Trauma
Risk for DM2
Ovarian Torsion
- Patient will be a woman, 15–30 years old or postmenopausal
- Sudden onset of unilateral (right > left) abdominal and pelvic pain
- Labs will show leukocytosis
- Imaging will show enlarged ovary or ovarian mass
- Definitive diagnosis and management: laparoscopy
Rectocele
History of childbirth, trauma, previous surgeries
PE will show a vaginal bulge at posterior vaginal wall or anterior rectum wall
Most commonly caused by weak pelvic muscles
Management includes managing constipation (high-fiber diet),
pessary device, and surgery when conservative measures fail
Endometrial cancer risk
Elderly
Nulliparity
Diabetes
Obesity
Menstrual irregularity
Estrogen monotherapy
Hypertension
Most common cause of fetal abortion before 20 weeks
Chromosomal Abnormalities
Tubo-Ovarian Abscess
- History of pelvic inflammatory disease (PID)
- Lower abdominal pain, fever, vaginal discharge
- PE will show unilateral adnexal tenderness
- Diagnosis is made by ultrasound
- Most commonly caused by a complication of pelvic inflammatory disease
- Treatment is intravenous antibiotics, surgical drainage, or both
Most common in women 15-25
Vulvovaginal Candidiasis
- Risk factors: diabetes, HIV, recent antibiotic use, steroid use, pregnancy, immunosuppression
- Sx: vulvar pruritus, dysuria, dyspareunia
- PE: white, cottage cheese-like discharge
- Labs: normal pH < 4.5, wet prep: budding yeast, pseudohyphae, hyphae
- Most commonly caused by Candida albicans
- Tx: topical azoles, oral fluconazole
Endometrial Cancer
- Peak incidence is in postmenopausal patients between age 60–70 years
- Most common type is adenocarcinoma
- Risk factors: nulliparity, obesity, unopposed estrogen (postmenopausal estrogen therapy without progestin), tamoxifen
- Sx: abnormal vaginal bleeding
- Dx: endometrial biopsy
- Tx: total hysterectomy AND bilateral salpingo-oophorectomy
Hyperemesis Gravidarum
- Peak incidence: weeks 8–12
- Weight loss
- Hypokalemia
- Ketonemia
- Rx: IVF with 5% dextrose, antiemetics
Genitourinary Syndrome of Menopause (Atrophic Vaginitis)
- Risk factors: natural or surgical menopause, antiestrogenic drugs
- Sx: dyspareunia, vulvar and vaginal dryness, bleeding, itching
- PE: pale, dry, shiny epithelium
- Caused by a decrease in estrogen
- Tx: lubricants, moisturizers, topical estrogen
Osteoporosis
Decline in bone mass that results in increased bone fragility and fracture risk
Risk factors: female sex, advancing age, chronic steroid use, alcohol or tobacco use, family history of fragility fracture
Diagnosis is made by DXA scan: T-score ≤ −2.5 or presence of a fragility fracture
Osteopenia: T-score -1.0 to -2.5
Tx:
Lifestyle: calcium, vitamin D, weight bearing exercise, smoking cessation
First line pharmacotherapy: bisphosphonates
Second line: SERMs, recombinant PTH, denosumab
Most common fracture: vertebral body compression fractures
Seizure prophylaxis in Pregnancy
Mag Sulfate
Lymphogranuloma Venereum
- Primarily seen in men who have sex with men
- History of recent travel to tropical and subtropical areas of the world
- Small, shallow painless genital ulcer
- PE will show tender inguinal or femoral lymphadenopathy
- Most commonly caused by Chlamydia trachomatis
- Treatment is doxycycline 100mg BID x 21 days
Rh Isoimmunization
Add more…..
- Rh-negative mothers exposed to Rh-positive blood → anti-Rh antibodies
- Subsequent pregnancies: jaundice, anemia, fetal hydrops, fetal death
- Anti-D globulin at 28 weeks (and within 72 hrs of delivery if infant is Rh+)
When do prolactin levels return to normal in a mother who is not nursing?
2 to 3 weeks following delivery.
(Prolactin is responsible for milk production after delivery)
Safe vaccines in pregnancy
Hep A
Hep B
Incativated Flu
Inactivated Polio
TDAP
Meningococcal
Rabies
Pneumococcal
COVID
Dont give (unsafe)
MMR, Live varicella, Oral Polio, BCG live
Unsafe vaccines for pregnancy
MMR
Live Varicella
Oral polio
BCG Live
How is menopause Diagnosed
Clinically is best
FSH is most sensitive test FSH>30
Increased LH
Decreased Estrogen
Cessation of Menses >1 year
Hot flashes, Mood changes, Etc.
Osteoporosis screening starts at what age
65
USPSTF
Hyperemesis Gravidarum
- Peak incidence: weeks 8–12
- Weight loss
- Hypokalemia
- Ketonemia
- Rx: IVF with 5% dextrose, antiemetics
ABX for UTI in Pregnancy
Nitrofurantoin (do not use in first trimester)
Fosfomycin
cephalexin
amoxicillin
bactrim
Pregnant Pyelonephritis =
IV ampicillin and Gentamicin or 3rd gen Ceph
Fibrocystic Breast Changes
- Risk factors: women 30−50 years old
- Sx: intermittent breast pain and tenderness that peak before each menstruation
- Ultrasound may show dense, prominent, fibroglandular tissue with cysts but no discernible mass
- Most commonly caused by fluctuating hormone levels during menstrual cycles
- Treatment is well-fitting supportive bras, applying heat to the breasts, or over-the-counter pain relievers
- Most common lesion of the breast
- Fibrocystic changes are generally benign and do not increase risk for breast cancer
Term for low amniotic fluid
Oligohydramnios
Preeclampsia
- Pregnancy > 20 weeks gestation or postpartum
- Visual disturbances, severe headaches, or asymptomatic
- Evaluation will show new-onset hypertension (≥ 140/90 mm Hg) with either proteinuria (≥ 300 mg/24 hr or urine protein: creatinine ratio ≥ 0.3) OR significant end-organ dysfunction
- Treatment: delivery at 37 weeks (without severe features) and 34 weeks (with severe features) AND prevention of seizures with magnesium sulfate and prevention of permanent maternal organ damage
- New-onset hypertension < 20 weeks gestation: suspect molar pregnancy
Which medication can be offered to women with risk factors for preeclampsia
can help prevent preeclampsia?
Aspirin
HPV types responsible for cancer
16
18
31
33
HPV types responsible for warts
6
11
42
Pelvic Inflammatory Disease (PID)
- History of multiple sexual partners or unprotected intercourse
- Lower abdominal pain, cervical motion tenderness, painful sexual intercourse
- PE will show mucopurulent cervical discharge
- Most commonly caused by Chlamydia trachomatis
- Outpatient treatment is ceftriaxone + doxycycline + metronidazole
- Fitz-Hugh-Curtis syndrome: perihepatitis + PID
Fibroadenoma
- Patient will be a woman of childbearing age
- PE: painless, firm, solitary, mobile, slowly growing breast mass
- Treatment: conservative management or surgical excision
- Most common breast tumor in adolescents
Reactive Fetal Heart rate
Two accelerations of 15 bpm above baseline for 15 seconds each in a 20-minute period
Shoulder Dystocia
Large fetal size
Turtle sign: fetal head pulled tight against perineum
Management
Empty bladder
McRoberts maneuver: flexing hips and legs
Suprapubic pressure
Delivery of posterior arm
Clavicle fracture
Last resort: Zavanelli maneuver (reinsert fetal head followed by C-section)
Danzanol or tamoxifen for
Fibrocystic breast changes pain
Tamoxifen
Tamoxifen has less side effects
Common Tocolytic Drugs
Mag sulfate, Indomethacin, Terbutaline, Nifedipine
What are tocolytics used for?
tocolytics are meant to suppress labor for a limited time to allow for the fetus to mature
Mag sulfate, Indomethacin, Terbutaline, Nifedipine
Nifedipine is the first-line agent for tocolytic therapy in women between 32–34 weeks gestation.
Nifedipine is the second line in women between 24–32 weeks gestation.
Magnesium sulfate is first line for women with suspected preterm labor between 24–32 weeks gestation because it provides neuroprotection against cerebral palsy and other types of severe motor dysfunction.
What is Oxytocin (pitocin) for?
Labor induction
Vulvar Cancer
History of human papillomavirus (types 16, 18, 33)
Vulvar lesion and pruritus
PE will show unifocal vulvar ulcer, plaque, or mass, predominantly on the labia majora
Most common type is squamous cell carcinoma (SCC)
Mag sulfate for preterm labor
First line suspected preterm labor between
24–32 weeks gestation
because it provides neuroprotection against cerebral palsy and other types of severe motor dysfunction.
Nifedipine for pre term labor
First-line agent for tocolytic therapy in women between
32–34 weeks gestation.
Second line in women between
24–32 weeks gestation.
First line steroid for preterm labor
Betamethasone
Intra-amniotic Infection (Chorioamnionitis)
- Infection, inflammation, or both of the amniotic fluid, placenta, fetus, fetal membranes, or decidua
- Risk factors: nulliparity, prolonged rupture of membranes, meconium-stained amniotic fluid, internal fetal or uterine contraction monitoring
- Genital tract infection: STIs, group B Streptococcus, bacterial vaginosis
- Rx: ampicillin + gentamicin
Placental Abruption
Patient will be in third trimester
History of hypertension, trauma, or cocaine use
Painful vaginal bleeding
Labs will show hypofibrinogenemia
Tx: fetal monitoring, hemodynamic stabilization, delivery
Uterine Prolapse
Risk factors: multiparity, age, decreasing estrogen levels, trauma
Rx: Kegel exercises, pessary, surgery
Stage 1 - Uterus ia in upper half of vagina
Stage 2 - Uterus is at introitus
Stage 3 - Uterus protrudes from vagina
Stage 4 - Al of uterus is protruding from vagina
Stages of labor
Stage 1 =
Time from onset of labor to complete cervical dilation
Stage 2 =
Time from complete cervical dilation to fetal expulsion
Stage 3 =
Time from Fetal Expulsion to Placenta expulsion
Bacterial Vaginosis
- Patient presents with malodorous vaginal discharge
- PE will show thin, gray or white discharge
- Labs will show pH > 4.5, clue cells
- Diagnosis is made by potassium hydroxide smear → fishy odor, whiff test, Amsel criteria
- Most commonly detected bacteria is Gardnerella vaginalis (usually due to decrease in Lactobacillus sp)
- Treatment is metronidazole
Lochia Rubra
Postpartum Discharge
red brown
Few days after delivery
Teratogenic Vitamin
Vitamin A
Cystocele first line
Pessary
Most important risk factor for breast cancer
Age is the most significant risk factor for breast cancer.
Mastitis
- Patient will be a breastfeeding mother
- Breast erythema, tenderness, fever
- Most commonly caused by Staph. aureus
- Management includes cool compresses and analgesics between feedings
- Antibiotics: dicloxacillin, cephalexin, TMP-SMX (MRSA), clindamycin (PCN allergy)
- Continue breast feeding to avoid progression to abscess
What tumor markers would you expect to be elevated in a patient with cervical cancer?
Beta-hCG, squamous cell carcinoma, and serum sialyl-Tn (STN).
Ovarian Cancer Tumor Marker
CA 125
Ovarian Cancer
*
Patient commonly presents with vague gastrointestinal symptoms, early satiety, bloating, abdominal or pelvic pain
* Adnexal mass
* Most common histologic type is epithelial carcinoma
* Tumor marker: CA 125
* Rule out germ cell tumors in patients < 30 years old with tumor markers such as hCG and AFP
* The most common cause of gynecologic death
* Routine screening not recommended (lack of benefit)
Requirements for preterm labor
Cervical Dilation over 3cm
or
Cervical length less than 20mm on transvag US
or
Cervical Length 20-30mm on trans vag US with +fibronectin
What med can cause premature closure of the ductus arteriosus.
Indomethacin
Abnormal Uterine Bleeding
Sx: heavy menstrual bleeding or intermenstrual bleeding
Etiology
Structural causes: polyp, adenomyosis, leiomyoma, malignancy or hyperplasia (PALM)
Nonstructual causes: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified (COEIN)
Laboratory assessment: pregnancy test, CBC
Endometrial tissue sampling for all women age ≥ 45 years
First-line imaging study: transvaginal ultrasound
Hormonal treatment is combination OCPs, IV estrogen, progestins, levonorgestrel IUD
What type of cancer does administration of estrogen-only therapy in a perimenopausal woman with an intact uterus increase the risk of?
Endometrial Cancer
When can the yolk sac be visualized
5 weeks
last til 11-12 weeks
Most common Bacterial STD
Chlamydia
Which syndrome is characterized by inflammation of the liver capsule and normal liver enzymes in a patient with a pelvic inflammatory disease?
Fitz-Hugh-Curtis syndrome.
Chlamydia Cervicitis
Diagnosis is made by nucleic acid amplification testing (NAAT)
Most commonly caused by Chlamydia trachomatis
Treatment is doxycycline (100 mg BID x 7 days), azithromycin should be used in pregnancy
Reinfection testing after treatment:
Nonpregnant: three months after treatment or at the first visit in the 12 months after treatment
Pregnant: four weeks after treatment
Most commonly reported sexually transmitted disease in the United States
Empirically treat for concomitant gonorrhea
The USPSTF recommends routine screening for chlamydia and gonorrhea in sexually active women < 25 years of age and in women age ≥ 25 years who are at increased risk
BV First Line
Flagyl
Bacterial Vaginosis
- Patient presents with malodorous vaginal discharge
- PE will show thin, gray or white discharge
- Labs will show pH > 4.5, clue cells
- Diagnosis is made by potassium hydroxide smear → fishy odor, whiff test, Amsel criteria
- Most commonly detected bacteria is Gardnerella vaginalis (usually due to decrease in Lactobacillus sp)
- Treatment is metronidazole
Outpatient Tx
PID
Ceftriaxone 500 im
plus
Doxy 100 bid x 14
plus
Flagyl 500 bid x 14
Inpatient Tx
PID
Cefotetan 2g IV q12
plus
Doxy PO 100mg Q 12
Pelvic Inflammatory Disease (PID)
- History of multiple sexual partners or unprotected intercourse
- Lower abdominal pain, cervical motion tenderness, painful sexual intercourse
- PE will show mucopurulent cervical discharge
- Most commonly caused by Chlamydia trachomatis
- Outpatient treatment is ceftriaxone + doxycycline + metronidazole
- Fitz-Hugh-Curtis syndrome: perihepatitis + PID
- Major complications of PID include tubo-ovarian abscess, chronic pelvic pain, infertility, and ectopic pregnancy.
Postpartum Hemorrhage
- Blood loss of ≥ 1,000 mL or bleeding associated with signs and symptoms of hypovolemia within 24 hours of birth regardless of route of delivery
- Most commonly caused by uterine atony
- PE will show an enlarged boggy uterus
- Management
- Empty bladder
- Bimanual exam and uterine massage
- Oxytocin and additional uterotonics (e.g., prostaglandins)
- Tamponade (balloon or surgery)
Causes of postpartum Hemorrhage
4 t”s
Tone = Uterine Atony (Most Common)
Trauma
Tissue = Retained placenta parts
Thrombin = Coagulopathy or thrombin disorder
Causes of postpartum Hemorrhage
4 t”s
Tone = Uterine Atony (Most Common)
Trauma
Tissue = Retained placenta parts
Thrombin = Coagulopathy or thrombin disorder
When is ophthalmia neonatorum most likely to appear in a newborn?
2-5 days after birth
Tx with prophylactic erythromycin ointment
Urge incontinence
Scheduled toileting, weight loss, and Kegel exercises are recommended for management of urge incontinence. First-line pharmacologic treatments include antimuscarinics (e.g., oxybutynin) and beta-adrenergics (e.g., mirabegron).
Topical vaginal estrogen may be used in postmenopausal women with urge or stress incontinence
Stress incontinence
Stress incontinence is caused by pelvic floor weakness, resulting in involuntary leakage of urine with increased intra-abdominal pressure (e.g., coughing, sneezing, laughing, exercise). Urethral hypermobility and intrinsic sphincter deficiency can result in stress incontinence. A bladder stress test is useful for confirming stress incontinence.
Topical vaginal estrogen may be used in postmenopausal women with urge or stress incontinence
Episiotomy complications
There are numerous complications of episiotomy as compared to spontaneous vaginal laceration.
These include extension of the incision deeper into the perineum that result in more third- and fourth-degree lacerations, a higher risk of infection, a higher risk of wound dehiscence, more postpartum pain, and more dyspareunia.
Additionally, episiotomy increases the risk of repeat vaginal laceration in a subsequent vaginal delivery.
Preferred type of episiotomy
A mediolateral incision is preferred over a posterior midline incision to reduce the risk of anal sphincter laceration.
It is typically performed in the second stage of labor when the fetus is crowning
Test of cure in pregnant chlamydia patient treated for infection.
Single dose azithromycin 1gram PO initial treatment
(add 500 IM Cef if pos for gonorrhea)
then test of cure in 3-4 weeks after
Also retesting is recommended 3 months after test of cure
Which sexually transmitted infection is associated with the congenital abnormality known as Hutchinson teeth?
Syphilis
What is the Quad Screen fro pregnancy
Alpha-fetoprotein
human chorionic gonadotropin
estriol
inhibin
Daily calcium supplement for pregnant women
1000mg
Cervical Cerclage
- Procedure to stitch the cervix to prevent premature delivery or miscarriage
- Used for those with cervical insufficiency, short cervix, previous preterm labor
Shirodkar procedure
McDonald procedure
Transabdominal procedure: open or laparoscopic approach
Abnormal uterine bleeding first line
Progesterone IUD
Most common cause of Primary Amenorrhea
Gonadal Dysgenesis
Other causes of primary amenorrhea include
Müllerian agenesis, physiologic delay of puberty, polycystic ovary syndrome, isolated gonadotropin-releasing hormone deficiency, transverse vaginal septum, weight loss or anorexia nervosa, and hypopituitarism.
Rare causes of primary amenorrhea include imperforate hymen, androgen insensitivity syndrome, prolactinoma, congenital adrenal hyperplasia, and hypothyroidism.
Sheehan Syndrome
Pituitary necrosis following massive obstetric hemorrhage
Causes GH, TSH, ACTH, FSH, LH deficiency
Failure to lactate
Amenorrhea
Anterior pituitary hormones
FSH
LH
TSH
PRL
ACH
GH
Posterior Pituitary Hormones
Oxytocin
ADH
Risks of HRT in post menopausal women
Increased risk in
Heart disease
Stroke
Thromboembolic disease
Breast cancer
Decreased risk in
Colorectal cancer
Fractures
Increased risk for what cancer with HRT in post menopausal women
Breast
PCOS first line tx
Combined OCP
Spironolactone is used as an adjunct in women who do not improve after 6 months of using combined oral contraceptives
Combined OCP pills help reduce what risk?
They reduce the risk of endometrial hyperplasia and cancer.
What is clomiphene used for
Ovulation induction
Genital Herpes Simplex
Sx: painful genital rash, may be asymptomatic
PE: grouped erythematous shallow cluster of vesicles and lymphadenopathy
Labs: multinucleated giant cells on Tzanck smear (poor sensitivity)
Dx: tissue PCR or viral culture
Most commonly caused by herpes simplex virus (HSV) type 2, but HSV-1 infections are increasing in frequency
Tx: acyclovir
Pregnancy: acyclovir for 7 days after primary infection and from 36 weeks to delivery
What can untreated PCOS lead to
Endometrial cancer
Vulvovaginal Candidiasis
Risk factors: diabetes, HIV, recent antibiotic use, steroid use, pregnancy, immunosuppression
Sx: vulvar pruritus, dysuria, dyspareunia
PE: white, cottage cheese-like discharge
Labs: normal pH < 4.5, wet prep: budding yeast, pseudohyphae, hyphae
Most commonly caused by Candida albicans
Tx: topical azoles, oral fluconazole
Definitive DX of Syphilis
Darkfield Microscopy
Syphilis
- Primary: painless chancre
- Secondary: lymphadenopathy, condyloma lata, rash on palms and soles
- Tertiary: gummas
- VDRL and RPR positive 1–4 weeks after infection
- Primary or secondary: IM benzathine penicillin G, 1 dose
- Tertiary: IM benzathine penicillin G qwk for 3 weeks
PMS bloating Edema Treatment
Spiroolactone
Acute Pyelonephritis
Sx: fever, dysuria, and flank pain
PE: CVA tenderness
Labs: UA + leukocyte esterase, nitrites, microscopy +WBCs, Gram stain, urine culture and susceptibility testing
Most commonly caused by Escherichia coli
Treatment depends on infection severity and community/host risk factors for resistant pathogens, options include fluoroquinolones, 3rd/4th gen cephalosporins, TMP-SMX. Critical illness or risk for multidrug resistant organisms: consider coverage for MRSA, VRE
Placenta Previa
Patient will in third trimester
Painless vaginal bleeding
Diagnosis is made by ultrasound (transvaginal > transabdominal)
Do not do a digital vaginal exam
Common Risk factors - Multiparity, increased age, and tobacco use.
Placenta Accreta
Placental attachment to the myometrium rather than the decidua, which causes the placenta not to spontaneously separate at delivery.
Invasion of the placenta into the myometrium.
Chancroid
Risk factors: sexually active
Sx: painful genital ulcers
PE: papule evolves to a pustule which ulcerates, ulcers on an erythematous base covered by a gray or yellow purulent exudate and painful lymphadenopathy (bubo)
Caused by Haemophilus ducreyi
Tx: ceftriaxone 250 mg IM or azithromycin 1 g oral
Placental Abruption
Patient will be in third trimester
History of hypertension, trauma, or cocaine use
Painful vaginal bleeding
Labs will show hypofibrinogenemia
Tx: fetal monitoring, hemodynamic stabilization, delivery
Pharm tx If breast cancer is hormone receptor positive
Tamoxifen
Can cause Uterine malignancy and thrombosis
Chlamydia Cervicitis
- Diagnosis is made by nucleic acid amplification testing (NAAT)
- Most commonly caused by Chlamydia trachomatis
- Treatment is doxycycline (100 mg BID x 7 days), azithromycin should be used in pregnancy
- Reinfection testing after treatment:
- Nonpregnant: three months after treatment or at the first visit in the 12 months after treatment
- Pregnant: four weeks after treatment
- Most commonly reported sexually transmitted disease in the United States
- Empirically treat for concomitant gonorrhea
- The USPSTF recommends routine screening for chlamydia and gonorrhea in sexually active women < 25 years of age and in women age ≥ 25 years who are at increased risk
Ovarian Cysts
Follicular: most common ovarian mass, non-neoplastic, regress spontaneously
Corpus luteum: most common ovarian mass in pregnancy, non-neoplastic, regress spontaneously
Dermoid: teratoma
Theca lutein: bilateral, ovarian enlargement
Endometrioid: endometriosis within ovary, chocolate cyst
Ultrasound
Chadwicks sign
is a bluish discoloration of the vulva, vagina, and cervix that occurs as the result of increased blood flow around 8–12 weeks gestation.
Goodells Sign
Softening of the cervix
Hegar sign
characterized by a softening of the uterus.
Osiander sign
Pulsations felt through the lateral vaginal fornices occur around 8 weeks gestation, and are associated with lateral implantation.
Piskacek sign
Asymmetrical enlargement of the uterus due to lateral implantation.
placental abruption common complication
DIC
What causes early decels
Compression of the fetal head causes a vagal reaction, which leads to an early deceleration of the fetal heart rate.
Primary Dysmenorrhea
*
Pain starts 1 or 2 days before menses
* Pain is only related to menstrual cycle
* ↑ PGF2alpha → ↑ uterine contractions
* Pain management: NSAIDs (first line) or acetaminophen
* Hormonal therapy: estrogen-progestin contraceptives
4 t”s of postpartum hemmorhage
Tone
Tissue
Trauma
Thrombosis
What nutrient is colostrum the highest in
Protein
Menopause treatment for symptoms. (hot flashes etc)
If uterus
Estrogen and Progesterone
If no uterus
Estorgen only
APGAR
- Appearance, pulse, grimace, activity, respiration
- Calculated at 1 and 5 minutes after birth
- Score of 0, 1, or 2 per section
- Baby with low score may require intervention
Elevated AFP in Pregnancy
Neural tube defects
What class of medications is associated with neural tube defects?
Antiepileptic medications, such as carbamazepine and valproic acid.
Abortion types with closed cervix
Threatened
complete
missed
Abortion types with open cervix
Inevitable
Incomplete
Septic
Fetal Station heights
-5 = highest, pelvis
0 = middle ischial spine
+5 = vaginal opening
Genitourinary Syndrome of Menopause (Atrophic Vaginitis)
Risk factors: natural or surgical menopause, anti estrogenic drugs
Sx: dyspareunia, vulvar and vaginal dryness, bleeding, itching
PE: pale, dry, shiny epithelium
Caused by a decrease in estrogen
Tx: lubricants, moisturizers, topical estrogen
Vaginal Atrophy tx
First line = moisturizers
then vaginal estrogen
then systemic estrogen
Trich s/s
yellow green discharge
fishy odor
flagellated
Vaginal edema, erythema, and punctate macular hemorrhages on the cervix, known as colpitis macularis or strawberry cervix
Nausea tx in preg
Pyridoxine
(vit b6)
Earliest a mole can be setected
8 weeks
Endometritis Tx
Clinda and Genta
(Abdominal pain, foul discharge, uterine tenderness post partum)
3 D’s
Dysmenorrhea, dyspareunia, and dyschezia.
Postpartum Endometritis
- Patient will be postpartum, early-onset disease < 48 hours after delivery (C-section more common)
- Fever, abdominal pain, foul-smelling lochia
- PE will show uterine tenderness
- Labs will show leukocytosis
- Most common postpartum infection
- Treatment is clindamycin + gentamicin
- GBS colonized: add ampicillin or use ampicillin-sulbactam
Complication of endometritis
Septic pelvic thrombophlebitis is a rare complication of postpartum endometritis that occurs when a thrombus occurs in a pelvic vein and becomes infected.
Preterm labor meds
Mag sulfate
Betamethasone
Ampicillin if grp B strep Unknown
At what age can you feel fetal movement
19 weeks
PID Out patietn ABX
Cef
Doxy
Flagyl
PID inpatient ABX
Cefotetan
Doxy
What is tachysystole
Side effect of oxytocin (most common)
5 contractions per 10 minutes for over 30 minutes
tx: reduce oxytocin
Active labor begins at what cervical dilation?
over 6 cm
RH incompatibility
Mom Negative
Dad Positive (Baby)
Rho Gam at 28 weeks and 72 hours before delivery
Fetal doppler of middle cerebral artery before 28 weeks
Colposcopy
No lesions - do endocervical biopsy sampling
Lesions, just do colposcopy
Fetal fibronectin
Used to determine risk of preterm birth
Retroverted uterus
Endometriosis
Most common endometriosis site
Ovaries
HRT puts you at risk for what cancer
Breast cancer
Previa vs abruption
Previa is painless
Abruption is painful
Vasa previa = Membrane rupture, Painless bleeding, Fetal distress
Excessive vomiting can cause what electrolyte imbalance
Hypokalemia
Cervical insufficiency can be linked to what disorder
Ehler danlos
