OBGYN Case Files Flashcards
Latent phase of labor?
- the initial part of labor where the cervix thins (effaces) more than it dilates
- dilation is less than 4 cm
Labor?
-cervical change accompanied by regular uterine contractions
Active phase of labor?
- portion of labor where dilation occurs more rapidly
- usually occurs when then cervix is dilated to > 4 cm
Normal amount of cervical dilation during the active phase for a: nulliparous woman? Woman with more than 1 vaginal delivery in the past?
- nulliparous = >/=1.2 cm/hr
- multiparous = >/= 1.5 cm/hr
Protraction of active phase of labor?
- cervical dilation during the active phase that is slower than the expected rate
- nulliparous = >/= 1.2 cm/hr
- multiparous = >/= 1.5 cm/hr
Arrest of active phase?
-no progress in the active phase of labor for 2 hrs
Stages of labor?
- First stage = onset of labor until the complete dilation of the cervix
- Second stage = complete cervical dilation to the delivery of an infant
- Third stage = delivery of the infant to the delivery of the placenta
Normal fetal HR?
-btwn 110-160bpm
Fetal bradycardia?
-baseline HR < 110 bpm
Fetal tachycardia?
-baseline HR > 160 bpm
Decelerations of fetal HR: what are they? 3 types?
- episodic changes below the baseline fetal HR
- three types:
1. Early = mirror image of the uterine contractions
2. Variable = abrupt, jagged dips below the baseline
3. Late = follow uterine contractions
Accelerations of fetal HR?
-episodes of the fetal HR increased at least 15 bpm above the baseline for at least 15 sec
What 3 things should be assessed when there is an abnormality in the labor?
- Powers - contraction strength or frequency
- Passenger
- Pelvis
* *3 P’s
Lower limit of normal for length of latent phase of labor in a nulliparous woman?
-</= 18-20 hrs
Lower limit of normal for length of latent phase of labor in a multiparous woman?
-</= 14 hrs
Lower limit of normal for length of second phase of labor in a nulliparous woman: w/ & w/out epidural?
-w/out epidural: </= 3 hrs
Lower limit of normal for length of second phase of labor in a multiparous woman: w/ & w/out epidural?
-w/out epidural: </= 2 hrs
Lower limit of normal for length of third phase of labor in a nulliparous woman?
- </= 30 min
Lower limit of normal for length of third phase of labor in a multiparous woman?
-</= 30 min
What are “adequate” contractions?
-contractions every 2-3 minutes that are firm on palpation and last at least 40-60 min
What type of decelerations in fetal HR are most common? What are they usually caused by?
- Variable
- caused by cord compression
What are early decelerations in fetal HR usually caused by?
- head compression
- they are usually benign
What do late decelerations in fetal HR suggest?
-fetal hypoxia
Station?
-refers to the relationship of the presenting bony part of the fetal head in relation to the ischial spines
Engagement?
-refers to the relationship of the widest diameter of the presenting part and its location w/ reference to the pelvic inlet
Bloody show?
- loss of cervical mucus plug
- sign of impending labor
- sticky mucus is mixed with the blood (this differentiates it from antepartum bleeding)
What are the 2 criteria of dx for preterm labor in a nulliparous woman for preterm labor?
- 2 cm dilation of cervix
2. 80% effacement of cervix
Fetal fibronectin: what is it used to dx? What does a negative resukt mean? How tested?
- used to dx risk of preterm birth
- negative = suggests no delivery within 1 week
- need to swab the posterior vaginal fornix for ffn BEFORE a digital examination
What changes in the cervix seen on transvaginal ultrasound are worrisome for preterm delivery risk?
- Shortened cervix
2. Lower segment changes = funneling or beaking of the amniotic cavity into the cervix
Preterm labor definition?
-cervical change associated with uterine contractions prior to 37 wks and after 20 weeks gestation
Tocolysis?
- pharmacologic agents used to delay delivery once preterm labor is diagnosed
- given if less than 34 wks
- most common agents used:
1. Indomethacin
2. Nifedipine
3. Terbutaline
4. Ritodrine
5. Magnesium sulfate
Antenatal steroids?
- given IM to pregnant woman to help decrease some of the complications of prematurity, esp resp distress syndrome (when given at > 28 wks)
- also can help prevent intraventricular hemorrhage in extreme prematurity (less than 28 wks)
- given if less than 34 wks
Fetal fibronectin assay?
- basement membrane protein that helps bind the placental membranes to the decidua of the uterus
- vaginal swab (before a digital exam) is used to detect its presence
- negative result = 99% chance of not delivering within 1 week
Cervical length assessment?
- transvaginal ultrasound is used to measure the cervical length
- cervical length less than 25 mm = increased risk of preterm delivery
- also an impinging of amniotic cavity into the cervix (= funneling) increases the risk of preterm delivery
Workup for preterm labor (6)?
- H&P - including pelvic exam, speculum exam assessment for ruptured membranes, cervical examination
- CBC
- Urine tox
- Test for gonorrhea and chlamydia
- Cultures for GBS
- US for fetal weight and presentation
Magnesium sulfate: use? MOA? Sfx? Contraindications?
- use: tocolytic agent
- MOA: competitively inhibits Ca for myeometrial use
- Sfx: pulmonary edema, resp depression, neonatal depression, & neonatal osteoporosis (long term)
- contraindications: myocardial damage, heart block, DM coma, CCB use
Terbutaline: use? MOA? Sfx? Contraindications?
- use: tocolytic agent
- MOA: beta-agonist, relaxes smooth muscles
- sfx: pulmonary edema, increased pulse pressure, hyperglycemia, hypokalemia, tachycardia
- CI: arrythmias, HTN, seizure disorder
Ritodrine: use? MOA? Sfx? CI?
- use: tocolytic agent
- MOA: beta-agonist, relaxes smooth muscles
- sfx: pulmonary edema, increased pulse pressure, hyperglycemia, hypokalemia, tachycardia
- CI: arrythmias, HTN, seizure disorder
Nifedipine: use? MOA? Sfx? Contraindications?
- use: tocolytic agent
- MOA: CCB, inhibits Ca ion influx into vascular smooth muscle
- sfx: CHF, MI, pulmonary edema, severe HTN
- CI: hypotension, DONT use with magnesium sulfate!
Indomethacin: use? MOA? Sfx? Contraindications?
- use: tocolytic agent
- MOA: NSAID, decreases prostaglandin synthesis
- sfx: closes fetus’ ductus arteriosus, leads to fetal pulmonary HTN & oligohydramnios
- CI: 3rd trimester bc of effects of ductus arteriosus
17-alpha-hydroxyprogesterone caproate; use? MOA? Sfx? Contraindications?
- use: tocolytic agent, proven to help prevent preterm birth when given as weekly injection from 20 wks to 36 wks
- MOA: synthetic progesterone, inhibits pituitary gonadotropin release; maintains pregnancy
- sfx: breast pain/tenderness, dizziness, abdominal pain, intermittent bleeding
- CI: undiagnosed vaginal bleeding
What infection is strongly associated with preterm labor?
-gonococcal cervicitis
What is the cause of significant variable decelerations in the fetal heart tracings?
-chord compression
3 Causes of sudden change of increasing variable decelerations in fetal heart tracings?
- Oligohydramnios –> less amniotic fluid to buffer cord compression (can be a sfx of indomethacin)
- Rupture of membranes
- Descent of fetal head
Dyspnea in a woman in preterm labor who was given tocolysis?
-usually due to pulmonary edema (which is a sfx of tocolysis)
Best tx for placenta accreta?
-hysterectomy
Placenta accreta?
- abnormal adhesion of the placenta to the uterine wall
- due to an abnormality of the decidua basalis layer of the uterus
- placental villi are attached to the myometrium
What can attempts to remove the placenta in placenta accreta lead to?
- hemorrhage
- maternal death
Placenta increta?
-abnormally implanted placenta that penetrates into the myometrium
Placenta percreta?
- abnormally implanted placenta that penetrates entirely through the myometrium to the serosa
- often can invade the bladder
5 Risk factors for placenta accreta?
- Low-lying placentation
- Placenta previa
- Prior c-section or other uterine scar
- Prior uterine curettage
- Fetal down syndrome
What position of the placenta has a higher risk for accreta: anterior or posterior?
-anterior
In placenta accreta which layer is defective: myometrial or endometrial lyr?
-endometrial lyr
What are the 2 most common complications of using Iv metotrexate as tx for placenta accreta?
- Hemorrhage
2. Infection –> the necrosis of the placental tissue can be a nidus for infection
Myomectomy incisions and risk of placenta accreta?
-incisions on the serosal (outside) surface if the uterus do not predispose to accreta –> bc the endometrium is not disturbed!
What causes placental polyps?
- placental polyps form from retained products of a term pregnancy or incomplete abortion
- occur inside the uterus
Myomectomy?
- surgical removal of uterine leiomyomas (fibroids)
- uterus remains preserved
Painless antepartum vaginal bleeding?
- think: placenta previa
- bleeding after 20 wks gestation
What should be done on physical exam for suspected placenta previa?
- ultrasound should be done BEFORE pelvic exam
- bc vaginal manipulation can induce bleeding
Antepartum vaginal bleeding?
-vaginal bleeding occurring after 20 wks gestation
Complete placenta previa?
-placenta completely covers the internal os of the uterine cervix
Partial placenta previa?
-placenta partially covers the internal cervical os
Marginal placenta previa?
-placenta abuts against internal os of the cervix
Low lying placenta?
-edge of placenta is within 2-3cm of the internal cervical os
Placental abruption?
-premature separation of a normally implanted placenta
Vasa previa?
- umbilical cord vessels that insert into the membranes with vessels overlying the internal cervical os
- can lead to fetal blood loss upon rupture of the membranes
Antepartum hemorrhage: what is it? 2 most common causes?
- significant vaginal bleeding after 20 wks gestation
- common causes:
1. Placenta abruption
2. Placenta previa
Main difference in the bleeding of placenta abruption and placenta previa?
- abruption usually presents with painful contractions
- previa is painless
Risk factors for placenta previa (5)?
- Grand multiparity
- Prior c-section
- Prior uterine curettage
- Previous placenta previa
- Multiple gestation
What is postcoital spotting a common complaint of?
-placenta previa
What should be done when placenta previa is dx early in pregnancy?
-repeate US at 34-35 wks, bc the placenta can transmigrate away from the cervix
Best tx of placenta abruption when near term (>34 wks)?
-delivery!
9 Risk factors for abruptio placentae?
- HTN –> both chronic and preeclampsia
- Cocaine use
- Short umbilical chord
- Trauma
- Uteroplacental insufficiency
- Submucous leiomyomata
- Sudden uterine decompression (hydramnious)
- Cigarette smoking
- Preterm premature rupture of membranes
Concealed abruption?
- bleeding occurs completely behind the placenta
- no eternal bleeding noted
- less common than overt hemorrhage, but more dangerous!!
Fetomaternal hemorrhage?
-fetal blood that enters into maternal circulation
Couvelaire uterus?
- bleeding into the myometrium of the uterus
- gives a discolored appearance to the uterine surface
Dx of placental abruption?
- difficult to dx
- clinical presentation is variable
- painful vaginal bleeding is the hallmark ssx
- ultrasound is not sensitive enough for dx
Tx for placental abruption?
- tx of choice is delivery
- no contraindications to vaginal delivery, but often c-section is done
3 Major risk factors for placental abruption?
- Hypertension
- Trauma
- Cocaine use
Soulder dystocia?
- inability of the fetal shoulders to deliver spontaneously
- due to impaction of anterior shoulder behind the maternal symphysis usually
McRoberts maneuver?
- maneuver used in shoulder dystocia
- maternal thighs are sharply flexed against the maternal abdomen
- allows the sacrum to straighten relative to the lumbar spine, and to rotate the symphysis pubis anteriorly towards the maternal head
Suprapubic pressure manuever?
- used for shoulder dystocia
- operator’s hand is used to push on the suprapubic region in a downward or in a lateral direction
- try to push fetal shoulder into an oblique plane behind the pubic symphysis
Erb’s palsy?
- brachial plexus injury that involves C5-6 nerve roots
- can result from downward traction of the anterior shoulder
- baby has wkness of deltoid and infraspinatus mm, and flexor mm of forearm
- arm often hangs limply by the side and is internally rotates
4 Instances in which shoulder dystocia should be suspected?
- Fetal macrosomia
- Maternal obesity
- Prolonged second stage of labor
- Gestational DM
Zavanelli maneuver?
-pushing the head back in and doing an immediate c-section
Chronic HTN?
- bp of 140/90 or greater before preg or at less than 20 wks preg
- or HTN that persists >12 wks postpartum
Gestational HTN?
-HTN w/out proteinuria at > 20 wks preg
Preeclampsia?
- HTN w/proteinuria at > 20wks
- caused by vasospasm
- proteinuria of > 300mg over 24hrs
Eclampsia?
-seizure disorder associated with preeclampsia
Severe preeclampsia?
- vasospasm associated w/ preeclampsia that is so severe that maternal end organs are threatened
- tx: delivery of baby regardless of gestational age
Superimposed preeclampsia?
-development of preeclampsia in a pt w/chronic HTN
Preeclampsia dx?
- 2 blood pressures taken properly and 6 hours appart that are > 140/90
- proteinuria of >300mg in a 24 hr urine collection
- nondependent edema (facial or hand) is often present, but not a diagnostic feature
Severe preeclampsia dx?
- bp of > 160/110 or 24 hr urine collection w/ proteinuria of > 500mg
- if no time for 24 hr collection, a dipstick with 3+ or 4+ protein is also diagnostic of severe preeclampsia
- also can be dx if have these sx of severe dz:
1. Headache
2. RUQ pain
3. Epigastric pain
4. Vision changes
Pathophysiology of preeclampsia?
- vasospasm
- “leaky vessels”
- origin unclear
Tox labs?
- to dx preeclampsia
- include:
1. CBC - platelet count & hemoconcentration
2. Liver function tests
3. LDH - elevated w/hemolysis
4. Uric acid - increases w/ preeclampsi
When is the greatest risk for eclampsia?
- Just prior to delivery
- During labor
- W/in first 24 hrs
What is the first sign of magnesium sulfate toxicity?
-hyporeflexia
What is the most common cause of maternal death due to eclampsia?
-intracerebral hemorrhage
What is given for seizure prophylaxis in preeclampsia?
-magnesium sulfate
Pregnant patient who presents at > 20 wks with seizures with no hx of epilepsy?
-is eclampsia until proven otherwise!
BP that is considered severe preeclampsia?
- > 160/110
Most common cause of significant proteinuria in pregnancy?
-preeclampsia
Definition of postpartum hemorrhage?
- loss of 500 mL or more after a vaginal delivery
- loss of 1000mL or more during c-section
Most common cause of postpartum hemorrhage?
-uterine atony
Uterine atony?
-uterus has not contracted, so the myometrium has not cut off the uterine spiral arteries that are supplying the placenta
First tx to use for uterine atony?
- Uterine massage
2. Dilute oxytocin
What should be done next if uterine massage and oxytocin do not help postpartum hemorrhage due to uterine atony?
-Prostaglandin F2-alpha
Methylergonovine maleate: what is it? Use? Contraindications?
- AKA: methergine
- ergot alkyloid agent that induces myometrial contractions
- tx for uterine atony
- contraindicated in HTN –> risk of stroke
Prostaglandin F2-alpha: what is it? MOA? Contraindications?
- prostaglandin compound
- causes smooth muscle contraction
- contraindicated in asthmatic pts
Definition of early postpartum hemorrhage or late?
- early = in first 24 hrs
- late = after first 24 hrs
Physical exam features of uterine atony?
-boggy uterus
7 Risk factors for uterine atony?
- Magnesium sulfate
- Oxytocin use during labor
- Rapid labor and/or delivery
- Overdistension of the uterus –> macrosomia, multifetal, hydramnios
- Intra-amniotic infection –> chorioamnionitis
- Prolonged labor
- High parity
Firm contracted uterus felt on PE postpartum?
- suspect genital tract laceration
- another cause of early postpartum hemorrhage
Most common cause of late postpartum hemorrhage?
-subinvolution of placental site
Subinvolution of placental site: when does this usually occur? Tx?
- what: eschar over the placental bed falls off, the lack of myometrial contraction leads to bleeding
- when: usually occurs 10-14 days after delivery, patient usually has no bleeding until about 2 wks after delivery, usually jot significantly anemic
- tx: oral ergot alkyloid
Classic presentation of retained products of conception?
- Uterine cramping
- Bleeding
- Fever
- Foul smelling lochia
Tx of retained products of conception?
- Uterine curettage
2. Broad spectrum antibiotics
3 Methods of tx for uterine atony that does not respond to medical tx?
- Ligation of blood supply to uterus to decrease pulse pressure = suture ligation of ascending branch of uterine artery or the utero-ovarian ligament, or internal iliac a.
- B-lynch stitch to try to compress the uterus with external suture “netting”
- Hysterectomy as last resort
Velamentous cord insertion?
- umbilical vessels separate before reaching the placenta, so they are not protected by the cord or the placenta
- they are only protected by a thin fold of amnion
- leaves the vessels susceptible to tearing after the rupture of the membranes
Vasa previa?
- umbilical vessels that are not protected by the cord or membranes
- the vessels cross the internal cervical os in front of the fetal presenting part
- this most commonly occurs with a velamentous cord insertion, or a placenta with one or more accessory lobe
Bilobed placenta?
- a placenta with either one or more accessory lobes
- AKA succenturiate-lobed placenta
Chorionicity?
- # of placentas in a twin or higher order gestation
- monozygotic twins can either be monochorionic or dichorionic
- dizygotic twins are always dichorionic
Amnionicity?
- number of amniotic sacs in a twin or higher order gestation
- monozygotic twins can be monoamnionic or di
- dizygotic twins are always dizygotic
What to do if the presenting twin is nonvertex?
-delivery via c-section
What should be done when vasa previa is suspected?
- do a doppler ultrasound to diagnose this
- schedule a c-section to be done before the rupture of the membranes (around 35-36wks)
- AVOID digital vaginal examination
Multiple gestations and pulmonary edema?
-the higher the number of pregnancies = more plasma volume = greater the risk of pulmonary edema
Pulmonary edema tx in pregnancy?
-IV furosemide
4 Signs of placental separation?
- Gush of blood
- Lengthening of the cord
- Globular and firm shape of the uterus
- Uterus rises up to the anterior abdominal wall
Abnormally retained placenta?
-third stage of labor (delivery of the placenta) that exceeds 30 minutes
What can be used to relax the uterus in the case of an inverted uterus (3)?
- Halothane
- Terbutaline
- Magnesium sulfate
Consequence of uterine inversion?
- hemorrhage
- almost always happens, even with proper tx
Which implantation site of the placenta is at the highest risk for uterine inversion?
-fundally implanted placenta
What should be done first if the placenta has not delivered in 30 minutes?
-attempt manual extraction of the placenta
What is the most common reason for hemorrhage in the inverted uterus?
-uterine atony, bc the inversion does not allow the uterus to properly contract and constrict the blood vessels
3 Prodromal ssx of herpes simplex virus?
- Burning
- Itching
- Tingling
What should be done in a pregnant woman with genital lesions or prodromal symptoms that are suspicious for HSV?
-recommend a c-section for delivery bc the patient is likely shedding virus
Tx of primary HSV infection in a pregnant pt?
- acyclovir
- can decrease the likelihood of recurrence and need for c-section
3 Ssx of intra-amniotic infection?
- Fever
- Uterine tenderness
- Fetal tachycardia
Tx of intra-amniotic infection?
-IV amp and gent
Method of delivery recommended with intra-amniotic infection?
-vaginal delivery is ok!
PROM?
- premature rupture of membranes
- rupture of membranes prior to the onset of labor
PPROM?
- preterm premature rupture of membranes
- rupture of membranes earlier than 37 weeks and prior to the onset of labor
Latency period?
-duration of time btwn ROM and the onset of labor
8 Risk factors for PPROM?
- Lower SES
- STDs
- Cigarette smoking
- History of cervical conization
- Emergency cerclage
- Multiple gestations
- Hydramnios
- Placental abruption
Up to what week are antenatal steroids given?
-32 wekks
What can cause chorioamnionitis WITHOUT rupture of membranes?
-listeria!!
What is one of the earliest signs of fetal hydrops?
- hydramnios (= excess amniotic fluid)
- seen in severe fetal anemia
What are 2 classical findings on PE of hydramnios?
- Larger uterine than predicted by dates
2. Hard to palpate fetal parts
Fetal hydrops?
- excess fluid in the body cavities (ex. Ascities, skin edema, pericardial effusion, and/or pleural effusion)
- a serious condition!
What 2 conditions could a sine wave on fetal heart tracings mean?
- Severe fetal anemia
2. Fetal asphyxia
Ssx of parvovirus in children? Adults?
Children: 1. Rash = "slapped cheek" 2. Fever Adults: 1. Myalgias 2. Lacy reticular rash that comes and goes
Ssx of B19 parvovirus infection in fetus?
- Aplastic anemia caused by destruction of erythroid precursors
- Hydrops fetalis
What would be seen on a CBC of a fetus with IUGR?
-polycythemia
5 Causes of hydramnios?
- GDM
- Isoimmunization (Rh)
- Syphillis
- Fetal cardiac arrhythmias
- Fetal intestinal atresia
Clear CXR w/ hypoxemia and clear lung sounds on exam?
-pulmonary embolism
pH: normal v pregnant?
- normal = 7.4
- pregnant = 7.45 –> resp alkylosis w/ partial metabolic compensation
PO2: normal v pregnancy?
- normal = 90-100
- pregnant = 95-105 –> increased tidal volume = higher oxygen level
PCO2: normal v pregnant?
- normal = 40
- pregnancy = 28 –> higher tidal volume = increased minute ventilation + lower PCO2
HCO3: normal v pregnant?
- normal = 24
- pregnant = 19 –> increased renal excretion of bicarb to compensate for resp alkylosis = lower serum bicarb = makes pregnant woman more prone to metabolic acidosis
Tx of pulmonary embolism in pregnancy?
- low-molecular-weight heparin
- given IV for first 5-7 days, then given orally for at least 3 mnths after the acute event
- then prophylactic heparinization should be used til the end of pregnancy and for 6 wks postpartum
What is the most common sign and symptom of a pulmonary embolism?
- sign = tachypnea
- symptom = dyspnea
What is the most common cause of maternal mortality today?
- thromboembolism
- pregnant women are predisposed to DVTs bc the uterus pushes on the vena cava and bc of the hypercoagulable state of pregnancy
What is the most common abnormality seen on an EKG in a pulmonary embolism?
-tachycardia!
What should be made sure of before artificially rupturing the amniotic sac? Why?
- the presenting part (preferably head) should be engaged
- if the membranes are ruptured when there is unengagement It causes an increased the risk of umbilical cord prolapse
Tx of umbilical cord prolapse?
- stat c-section!
- keep the pt in the trendelenburg position or keep hand in vagina to elevate the presenting part off the cord
Engagement?
-the largest transverse diameter of the fetal head (biparietal) has negotiated the bony pelvic inlet
Fetal bradycardia?
-baseline fetal heart rate < 110 bpm for 10 min or more
Umbilical cord prolapse?
- umbilical cord enters the cervical os in front of the presenting part
- ROM before engagement can increase the risk for this!
What are the initial steps to take in fetal bradycardia?
- Place the mother on their –> moves uterus off the great vessels = improve blood flow to the heart
- IV fluid bolus if the pt is possibly volume depleted
- Give 100% oxygen via face mask
- Stop oxytocin if its being given
What can hyperstimulation with oxytocin cause? Tx?
- can lead to fetal bradycardia
- the uterus becomes tetanic or the uterine contractions are frequent (every 1 min)
- Tx: beta-agonist (ex. Terbutaline) = relaxes uterine musculature
How can an epidural cause fetal bradycardia? Tx?
- can cause hypotension
- tx: IV hydration first, if not working, give ephedrine (=pressor agent)
In a woman with a prior c-section, what can also be the cause of fetal bradycardia?
-uterine rupture!
What is the most common ssx of uterine rupture?
-fetal HR abnormality
Fetal bradycardia in a pt given misoprostol?
- given for cervical ripening
- associated with hyper stimulation of the uterus
Misoprostol v prostaglandins for cervical ripening?
- misoprostol has higher risk of uterine hyperstimulation
- prostaglandins are more expensive
Hyperstimulation and fetal bradycardia?
-the frequent contractions cause frequent vasoconstrictions on the uterine blood vessels –> decreases the amnt of blood that arrives to the fetus over time
How much dilation is required to be able to monitor the fetal pH via fetal scalp electrode?
-at least 4 cm
Tx for hyperstimulation of the uterus?
-IV terbutaline
Two reasons why pregnancy causes a hypercoagulable state?
- Increased levels of clotting factors –> esp fibrinogen
2. Venous stasis
Homans sign?
- Dorsiflexion if the foot causes tenderness in the calf
- test for DVT –> poor test, might even cause an embolization of a clot
Dx of DVT?
- noninvasive doppler flow test
- venography with contrast dye can also be used, but NOT in a pregnant pt!
Which mode of delivery increases the risk for DVTs?
-c-section
3 ssx of DVT?
- Muscle pain
- Deep linear cord in the calf felt on exam
- Swelling of the lower extremity (unilateral) –> greater than 2 cm difference in size of calf
* *these are all very nonspecific! DVT cannot be dx by exam alone
Tx for DVT in pregancy?
- Anticoagulation w/ IV heparin for 5-7 days, then orally for 3 mnths, can be given until end of pregnancy and for 6 wks postpartum
- warfarin can cause congenital defects
- heparin can be more easily reversed - Bed Rest
- Extremity elevation
How can anticoagulants cause osteoporosis?
- by inhibiting vitamin K
- vitamin K is involved in bone metabolism
Where are DVTs associated with gynecological surgeries most commonly found?
- Lower extremities
2. Pelvic veins
How do surgeries cause an increased risk for DVTs?
- think Virchow’s triad
1. Stasis –> pt is operated on in the supine position + anesthesia causes vasodilation
2. Hypercoagulability –> the body recognizes blood loss during the procedure so the pt becomes hypercoagulable + more clotting factors are produced in effort to stop the bleeding
3. Vascular wall injury –> can occur from excessive vasodilation that is caused by anesthesia + any injuries to blood vessels = accumulation of clotting factors at the site of injury
What contraceptives are contraindicated in a woman with a prior DVT or the postpartum woman?
- any that contain estrogen bc its thrombogenic
- progestin-only are ok, progestin is not thrombogenic
Chlamydia and pregnancy?
- a chlamydial endocervical infection has not been proved to cause any adverse problems in pregnancy
- can cause neonatal conjunctivitis (not prevented by the erythromycin eye ointment given at birth)
- can cause pneumonia
When is the best time to screen for chlamydia during pregnancy? Tx?
- bc of the neonatal diseases it can cause it is best to screen during the last trimester
- make sure to repeat testing in third trimester, even if they were infected an treated earlier in the pregnancy –> reinfection is common!
- tx: erythromycin or amoxicillin for 7 days or azithromycin as a 1x dose
What is the most common cause of conjunctivitis within the first month of life?
-chlamydia
Why is tetracycline contraindicated in pregnancy?
- it can stain the teeth of the fetus
- ex doxycycline
Gonococcal cervicitis and pregnancy?
- associated w/:
1. Abortion
2. Preterm labor
3. PPROM
4. Chorioamnionitis
5. Neonatal sepsis
6. Postpartum infection
7. Disseminated gonorrhea –> more common in pregnant women
Tx for gonorrhea?
-IM ceftriaxone + antibiotics for a chlamydial infection (ex erythromycin) bc pts are often infected with both
What is the HIV viral load goal in pregnant women? How often should it be checked?
- goal is less than 1000 RNA copies per milliliter
- viral load should be checked every month, until the level is undetectable
HIV and delivery?
- mothers with viral loads that are not detectable will have very low chance of vertical transmission
- women with viral loads less than 1000 can deliver vaginally without transmission –> higher loads should be offered delivery via c-section BEFORE the rupture of membranes or labor
- woman who are delivering vaginally should receive IV zidovudine
- if labor or rupture of membranes already started/occurred, give IV zidovudine and allow labor to continue, but try to minimize trauma to baby!!
Where does chlamydia have propensity to?
-for columnar epithelium
What organism is associated with late postpartum endometritis?
-chlamydia
PUPPP?
- Puritic Urticarial Papules and Plaques of Pregnancy
- erythematous plapules and hives that begin in the abdominal are and often spread to the buttocks
Herpes gestationis?
- intense itching in pregnancy that is associated with erythematous blisters on the abdomen and extremities
- autoimmune in nature, NOT associated with herpes virus
- now known as pemphigoid gestationis
Cholestasis and puritis?
-bile salts are incompletely cleared by the liver, so they accumulate in the body & are deposited into the dermis –> causes puritis
Cholestasis in pregnancy?
- intrahepatic cholestasis of unknown etiology in oegnancy
- pt complains of pruritis w/or without jaundince
- no skin rash!
What is the most common cause of pruritis in pregnancy?
-intrahepatic cholestasis of pregnancy
How can a dx of intrahepatic cholestasis of pregnancy be dx?
- via increased levels of circulating bile acids
- no rash is seen on PE!
What 3 fetal consequences is cholestasis of pregnancy associated with?
- Prematurity
- Fetal distress
- Fetal loss
Tx of cholestasis of pregnancy?
- antihistamines
- cornstartch baths
What trimester is cholestasis of pregnancy is usually seen in?
-3rd!
What trimester is herpes gestations usually seen in?
-2nd!
Tx of herpes gestationis?
-oral corticosteroids
Tx of PUPPP?
-topical steroids and antihistamines
Ddx of itching in pregnancy?
- Contact dermatitis
- PUPPP
- Herpes gestationis
- Intra-hepatic Cholestasis of pregnancy
Effects of PUPPP on pregnancy?
-not known to cause any adverse effects
When is PUPPP most commonly seen?
- usually during the first pregnancy, doesn’t recurr
- usually starts in 35-36th week
What is the most common cause of hyperTH in the US?
-Graves dz
Tx of hyperthyroidism in pregnancy?
-propylthiouracil
Tx of thyroid storm?
- Beta-blocker (propranolol) –> controls tachycardia, hyperTH can cause congestive heart failure
- Corticosteroids –> prevents T4 from converting to T3 peripherally
- Additional propylthiouracil
- Acetaminophen –> to decrease temp (or cooling blankets can be used)
How can PTU affect WBCs?
- PTH can induce bone marrow aplasia –> leukopenia
- rare
Thyroid storm?
-extreme thyrotoxicosis that leads to CNS dysfunction (coma or delerium) and autonomic instability (hyoerthermia, HTN, or hypotension)
Two medical tx for hyperTH?
- Propylthiouracil –> tx of choice in pregnancy!!!
2. Methimazole
Thyroid level changes seen in pregnancy? Why?
- increased estrogen in pregnancy causes an increase in thyroid-binding globulin and an increase in total T4
- does not change active or free T4 or the TSH
Most common cause of postpartum hyperTH?
- destructive lymphocytic thyroiditis
- high corticosteroid levels during pregnancy suppress the autoimmune antibodies –> causes a flare up to occur postpartum when they corticosteroid levels fall after delivery of the placenta
- usually seen 1-4 mnths postpartum
Acute onset of colicky, lower abdominal pain and nausea/vomiting in a pregnant woman?
-think: ovarian torsion = twisting of the ovarian vessels which leads to ischemia
When is ovarian torsion typically seen in pregnancy?
-before 14 wks gestation when the uterus rises above the pelvic brim or immediately postpartum when the uterus rapidly involutes
What are 5 common causes of abdominal pain in a pregnancy?
- Appendicitis
- Acute cholecystitis
- Ovarian torsion
- Placental abruption
- Ectopic pregnancy
Appendicitis & pregnancy: when is it commonly seen?
-any trimester
Appendicitis & pregnancy: where is the pain located?
-right LQ –> right flank
Appendicitis & pregnancy: 6 associated ssx?
- Nausea
- Vomiting
- Anorexia
- Leukocytosis
- Fever
- RLQ –> flank pain (superior and lateral to McBurney’s point bc the uterus pushes the appendix upwards and outwards toward the flank)
Cholecystitis & pregnancy: when is it commonly seen?
-after the first trimester
Cholecystitis & pregnancy: 6 associated ssx?
- Nausea
- Vomiting
- Anorexia
- Leukocytosis
- Fever
- RUQ pain
Ovarian Torsion & pregnancy: 3 Ssx?
- Unilateral abdominal or pelvic pain
- Nausea
- Vomiting
Placental abruption: when is it commonly seen?
-second & third trimesters
Placental abruption: 3 Ssx?
- Midline persistent uterine pain
- Vaginal bleeding
- Abnormal fetal heart tracings
Ectopic pregnancy: 5 Ssx?
- Pelvic or abdominal pain, usually unilateral
- Nausea
- Vomiting
- Syncope
- Spotting
Biliary colic?
- ssx of the presence of gallstones in the absence of infection or fever:
1. Bloated feeling after meals
2. RUQ pain following meals
3. Nausea following meals
4. Emesis following meals
Dx of cholelithiasis?
- via abdominal ultrasound
- see gallstones and dilation and thickening of gallbladder wall
Tx of biliary colic in pregnancy?
-low-fat diet and observation until postpartum
What is the most common complication of a benign ovarian cyst?
- ovarian torsion
- its the most serious complication too!
Risk factors for placental abruption (6)?
- Previous abruption
- Hypertensive dz in pregnancy
- Trauma
- Cocaine use
- Smoking
- PPROM
Tx of placental abruption?
-delivery, usually via c-section
What is the leading cause of mortality in the first and second trimesters of pregnancy?
-ectopic pregnancies
Dx of ectopic pregnancy?
- transvaginal ultrasound
- serum hCG
Pt that is hypotensive, tachycardic, and feels faint?
-think: hemorrhagic shock
Abdominal pain, abdominal distention,rebound tenderness, and positive fluid wave?
-think hemoperitoneum
Most common cause of hemoperitoneum in a pregnant woman?
-ectopic pregnancy that has ruptured
Float test?
- when the tissue a pregnant woman passes is placed in saline and it floats in a “frond pattern”
- test is > 95% accurate for the presence of chorionic villi
Corpus luteum
- physiologic ovarian cyst formed from mature graafian follicles following ovulation
- secretes progesterone, secretes the majority until about 10 wks of gestation
Hemorrhagic corpus luteum?
- bleeding occuring in a corpus luteum
- may cause a hemoperitoneum or cyst enlargement
Dx of hemorrhagic corpus luteum?
- ultrasound may show free intraperitoneal fluid and/or fluid around ovary
- dx is confirmed via laparoscopy
Tx of ruptured corpus luteal cyst?
- secure hemostasis, once bleeding stops, no further tx is needed
- if bleeding continues, cystectomy needed, with the preservation of the normal portion of the ovary
Surgical removal of the corpus luteum during pregnancy?
- if removed before 10-12 wks exogenous progesterone is needed, bc the corpus luteum is the main supplier up to that point
- if removed after, no supplementation is needed bc the placenta has taken over in progesterone production
Location of gallbladder during pregnancy?
-doesnt move
Degeneration of fibroids during pregnancy?
- due to the increase in estrogen levels which cause growth of the fibroid –> fibroid outgrows its blood supply = ischemia and pain
- pain is typically localized to over the leiomyoma
Increased hCG levels and no chorionic villi on uterine curettage?
-ectopic pregnancy!!
What is the earliest sign of hypovolemia?
-decreased urine output (due to decreased blood flow to kidneys via compensation methods that increase blood flow to the rest of the body and vital organs)
Which patients are more susceptible to hemorrhagic corpus luteum?
- pts who have a higher bleeding tendency:
1. Congenital (ex von Willebrands)
2. Iatrogenic (ex coumadin)
By the time hypotension is noticed in a young/healthy pt, how much blood volume has been lost?
-30-40%
3 Contraindications to IUDs?
- Recent sexually transmitted dz
- Behavior that increases risk for STDs
- Abnormal size/shape of uterus
Yuzpe regimen?
- 2 tablets of ovral oral contraceptives (estradiol + levonorgestrel) at time zero and 2 tablets after 12 hrs
- needs to be taken within 72 hrs of unprotected intercourse
Plan B?
- progestin only
- levonorgestrel 0.75mg taken orally at time zero and the same dose after 12 hrs
- must be given within 72 hrs of unprotected intercourse
What can be a sfx of the patch?
-more nausea
What can the vaginal ring cause?
-vaginal irritation and/or vaginal discharge
MOA of combined oral contraceptives/ring (4)?
- Inhibits ovulation
- Thickens cervical mucus to inhibit sperm penetration
- Alters motility of uterus and fallopian tubes
- Thins the endometrium
Who are progestin-only pills best for?
-women who want to breastfeed
MOA of progestin-only pills?
- Thickens cervical mucus to inhibit sperm penetration
- Alters motility of uterus and fallopian tubes
- Thins the endometrium
MOA Depo?
- Inhibits ovulation
- Thins endometrium
- Alters cervical mucous to inhibit sperm penetration
What form of birth control would be best suited for a patient with sickle cell dz?
-depo
What form of contraception would be best for a pt with epilepsy?
-depo
Implanon MOA?
- Inhibits ovulation
- Thins endometrium
- Thickens cervical mucous to inhibit sperm penetration
What can inplanon cause?
-irregular vaginal bleeding
What is implanon?
-levonorgestrel subdermal implant in arm
Levonorgestrel IUD: MOA?
- Thickens cervical mucous
- Thins endometrium
* *mirena
Copper-T IUD: MOA?
- Inhibits sperm migration and viability
- Changes transport speed of ovum
- Damages ovum
What form of contraception is contraindicated in a pt with Wilson’s dz?
-copper IUD
What is one sfx of a copper IUD?
-may cause more bleeding or dysmenorrhea
What are 2 sfx of a diaphragm?
- Higher rate of UTIs
2. Increased risk of ulceration of vaginal epithelium with prolonged use
5 Main risks of combined oral contraception?
- Venous thromboembolism
- Strokes, esp in pts with migraines w/aura
- Myocardial infarction, in women > 35 who are smokers
- Increased risk of cholelithiasis
- Benign hepatic tumors
What do oral combined contraceptives decrease a woman’s risk of?
- Endometrial cancer
- Ovarian cancer
- Benign breast disease
How often are depo shots needed?
-every 3 mnths
How long does implanon last for?
-3 yrs
About how long does it take for fertility to return after contraception?
- pills, patches, or rings = 2 weeks
- depo = 4 weeks
How long does the T380A last for?
- 10 years
- copper IUD
How long does the levonoregestrel-releasing IUD last for?
-5 yrs
2 Most common emergency contraception methods?
- Yuzpe method
2. Progestin-only regimen
IUD as emergency contraceptive?
-can be inserted up to 5days after unprotected intercourse for emergency contraception
What is one sfx of depo?
-associated with loss of bone mineral density, esp in adolescents
What form of contraception is associated with the greatest risk of DVTs?
-the patch
Bacterial vaginosis?
-condition of excessive anaerobic bacteria in the vagina, leads to an alkaline discharge
Candida vulvovaginitis?
-vaginal and/or vulvar infection that is caused by. Candida species, usually w/ heterogenous discharge and inflammation
Trichomonas vaginitis?
- infection of vagina caused by protozoa trichomonas vaginalis
- usually associated with frothy green discharge and an intense inflammatory response
- also see erythematous, “strawberry cervix”
Whiff test?
-adding KOH to the prep will cause an increase in fishy odor of BV and trich
Tx of BV?
-oral or vaginal metronidazole
Trich tx?
- high one time oral dose of metronidazole
- tx partner too!!
BV, trich, & candida: acidic or basic?
- BV & trich = alkaline
- candida = acidic
Canidiasis tx?
-oral diflucan or topical terconazole, or topical miconazole
4 Possible complications of BV?
- Endimetritis
- PID
- Preterm delivery
- PPROM
5 possible complications of PCOS?
- DM
- Endometrial cancer
- Hyperlipidemia
- Metabolic syndrome
- CV dz
Dx criteria of PCOS?
At least 2:
- Oligo-ovulation ( oligomenorrhea)
- Hyperandrogenism
- Ovarian cysts on ultrasound (> 12)
In females, where is testosterone mainly produced?
-in the ovaries
In females, where is DHEAS mainly produced?
-adrenal gland
Tx for dysfunctional bleeding in PCOS?
- combined OCPs
- regulate the bleeding and limit the unopposed estrogen (= reduce endometrial cancer risk)
Progestin challenge test?
-Positive = start bleeding with a 5 day or 10 day course of oral progestin
4 Stages of pubertal development?
- Thelarche = breast buds
- Pubarche/adrenarche = pubic/axillary hair
- Growth spurt
- Menarche
Hypergonadotropic hypogonadism?
- high FSH, low estrogen
- due to gonadal deficiency
- most common cause = Turner’s syndrome
- other causes = ovarian damage due to exposure to ionizing radiation, chemo, inflammation, or torsion
Hypogonadotropic hypogonadism?
- low FSH, low estrogen
- secondary to central defect
- ex hypothalamic dysfunction, eating disorder, poor nutrition, extremes in exercise, chronic illness, stress, hypoTH, Cushing syndrome, pituitary adenomas, or craniopharyngiomas (most common associated neoplasm)
Delayed puberty?
-no secondary sexual characteristics by age 14 in females
Primary amenorrhea?
-no menarche by age 16
Ssx of septic abortion?
- bleeding and/or spotting in first trimester
- plus ssx of infection:
1. Lower abdominal tenderness
2. Cervical motion tenderness
3. Foul-smelling vaginal discharge
Tx of septic abortion?
- four general parts:
1. Maintain BP
2. Monitor BP, oxygenation, and urine output
3. Start antibiotic tx: clinda and gent
4. Perform uterine curettage
What is one of the earliest ssx of septic shock?
Oliguria
What is the most common mechanism of septic abortion?
-ascending infection
What is the one infection that can spread hematogenously and cause chorioamnionitis?
-listeria! (From soft cheeses)
Threatened abortion?
-pregnancy less than 20 weeks’ gestation associated with vaginal bleeding, generally w/out cervical dilation
Inevitable abortion?
- pregnancy less than 20 wks associated w/ cramping, bleeding, and cervical dilation
- there is no passage of tissue
Incomplete aborption?
- a pregnancy less than 20 wks associated w/ cramping, vaginal bleeding, an open cervical os, some passage of tissue per vagina, but some retained in utero
- Cervix remains open, due to continued uterine contractions in effort to expel the retained tissue
Completed abortion?
- pregnancy less than 20 wks in which all the products of conception have passed
- cervix is usually closed (all tissue has been expelled, uterus not contracting, cervix closes)
Missed abortion?
-pregnancy less than 20 wks gestation w/ embryonic or fetal demise, but w/ no sx such as bleeding or cramping
Incompetent cervix v inevitable abortion?
- incompetent cervix = painless dilation of the cervix
- inevitable abortion = uterine contractions (cramping) leads to cervical dilation
Cerclage?
-surgical stitch of the internal os
What is seen on ultrasound in a molar pregnancy?
-snow storm pattern
What can postcoital spotting be a sign of?
-cervical cancer
What is the mean age for presentation of cervical cancer?
-age 51
6 Risk factors for cervical cancer?
- Early age of childbearing
- Cigarette smoking
- Hx of STDs (esp syphilis and HPV)
- Early age of coitus
- Multiple sexual partners
- HIV infection
Cervical intraepithelial neoplasia?
-preinvasive lesions of the cervix w/abnormal cellular maturation, nuclear enlargement, and atypia
Human Papillomavirus?
- AKA: HPV
- circular, dbl stranded DNA virus
- can become incorporated into cervical squamous epithelium
- predisposes cells for dysplasia and/or cancer
Radical hysterectomy?
- removal of uterus, cervix, and supportive ligaments
- ligaments = cardinal ligament, uterosacral ligament, and proximal vagina
Radiation bracytherapy?
-radioactive implants placed near the tumor bed
Radiation teletherapy?
-external beam radiation where the target is at some distance from radiation source
HPV vaccine?
- killed virus vaccine
- for females and males aged 9-26
- against types 16 & 18 (associated with cervical cancer) + 6 & 11 (associated with venereal warts)
Where do the majority of cervical dysplasia and cancers arise?
-near the squamocolumnar junction of the cervix
What should be done when a woman presents with a cervical mass?
- a bx of the mass should be taken
- dont do a pap smear first!
What is the most common cause of death in cervical cancer?
- bilateral urethral obstruction, which leads to uremia
- obstruction can also lead to hydronephrosis
Pap smears after hysterectomy in a woman with a history of cervical dysplasia?
-still need to be done of the vaginal cuff
What type of cells are most common in cervical cancer?
-squamous (not adenomatous)
At what age are pap smears no longer needed?
-after age 65-70 as long as there is no hx of cervical dz
Advanced maternal age?
-35+ at estimated delivery date
Isoimmunization?
- development of specific antibodies as a result of antigenic stimulation by material from RBCs of another individual
- ex Rh isoimmunization
Asymptomatic bacteriuria?
-urine culture of 100,000 or more of a pure pathogen of a mid stream-voided specimen
Glycosuria in pregnancy?
-normal bc of increased GFR, which delivers more glucose to the kidneys
When is a measurement of fundal height most acuurate?
-btwn wks 20-34
What discrepancy warrants an US in fundal height/wks?
-being 3 or + more cm off
What is considered anemia in pregnancy?
- < 10.5
What should be done for a pregnant female who is not rubella immune?
- advise to stay away from sick ppl
- give the vaccine postpartum
- the vaccine is a live vaccine and is contraindicated in pregnancy
When is rhogam typically given?
- in an Rh negative female at week 28
- and after delivery if the baby is Rh positive
What to do in pregnant woman who is hep B surface antigen positive?
- check LFTs and hel serology to determine if she is a chronic carrier v active hep
- give baby HBIG and hep B vaccine after birth
When is the 1 hr GDM screen done?
- weeks 26-28
- AKA GST
when are GBS cultures typically done?
-35-37 wks
What 2 things can cause vaginal bleeding after 20 wks?
- Placenta previa
2. Placenta abruption
Prevention of repeat abruption?
-induce labor at or slightly before the previous abruption
Plasma volume and pregnancy?
-its increased by 50%
Which antibodies are worrisome in pregnancy: Lewis/Kell/Duffy?
“Lewis lives, Kell kills, Duffy dies”
-fetal risk is not great unless the titer is 1:8 or higher
The presence of which antigen markedly increases the vertical transmission of hep B?
-hep E antigen
Cystocele?
- defect in pelvic muscular support of bladder
- bladder falls down into the vagina
- urethra is often hypermobile
- anterior pelvic organ prolapse (POP) defect
Enterocele?
- defect of pelvic muscular support of uterus and cervix (if still there) or vaginal cuff (if hysterectomy was done)
- small bowel and/or omentum pushes the organs into the vagina
- this is a central POP defect
Rectocele?
- defect of pelvic muscular support of rectum
- allows rectum to impinge into vagina
- pt can have constipation of difficulty evacuating stool
- posterior POP defect
Paravaginal defect?
- defect in levator ani attachment to the lateral pelvic side wall –> lack of support of the vagina
- lateral pelvic defect
7 Risks for POP?
- Multiple vaginal births
- Coughing
- Lifting
- Lack of estrogen
- Genetic predisposition
- Connective tissue disorder
- Obesity
Procidentia?
-when the entire uterus is prolapsed out the patient’s introitus
What is the most common cause of postmenopausal bleeding?
-atrophic endometrium
Atrophic endometrium?
- most common cause of postmenopausal bleeding
- caused by friable tissue in the endometrium or vaginal that is due to low estrogen
What thickness of an endometrial stripe is abnormal in a postmenopausal woman?
- > 5 mm
What must be ruled out in any pt with postmenopausal bleeding?
- endometrial cancer!
- will be present 20% of the time if the pt is not on hormonal tx and complaining of bleeding
What is the most common malignancy of the female Gu tract?
-endometrial
9 Risk factors for endometrial cancer?
- Early menarche
- Late menopause
- Obesity
- Chronic anovulation
- Estrogen-secreting ovarian tumors
- Ingestion of unopposed estrogen
- HTN
- DM
- Personal or family Hx of breast or ovarian cancer
What can atypical glandular cells of pap smear mean? What should be done next?
- can mean: endocervical or endometrial cancer
- next: colposcopic exam, curettage of endocervix, and endometrial sampling
When is endometrial cancer typically more aggressive?
-in a pt without a hx of anovulation
Common Ssx of ectopic pregnancy?
- Abdominal pain (can get acutely worse if a rupture occurs)
- Amenorrhea for 4-6wks
- Irregular spotting
- Shoulder pain (bc the diaphragm gets irritated by blood if there is a rupture)
- Tachicardia
- Syncope
- Hypotension
- Adnexal tenderness
- Adnexal mass
What is more sensitive to detect pregnancies: transvaginal or transabdominal US? At what beta HCG levels can each method detect a pregnancy?
-transvaginal is more sesnitive, can detect at > 1,500
-
How much should the hCG rise in 48 hrs in a normal pregnancy?
-By at least 66%
What should the progesterone level be in a normal pregnancy?
> 25 ng/mL
Up to what age should pap smears be done?
-65 yrs, as long as prior pap smears have all been normal
At what age should bone density studies begin?
-age 65 if they have no other risk factors
Leiomyomata?
-benign, smooth muscle tumors, usually in the uterus
Leiomyosarcoma?
-malignant, smooth muscle tumor, with numerous mitosesw
Submucous fibroid?
- leiomyomata that are primarily on the endometrial side of the uterus
- impinge on the uterine cavity
Intramural fibroid?
-leiomyomata that are primarily in the uterine muscle
Subserosal fibroid?
- leiomyomata that are primarily on the outside of the uterus, on the serosal surface
- PE may reveal a “knobby” sensation
Pedunculated fibroid?
-leiomyomata that is on a stalk
Carneous degeneration?
- changes in the leiomyomata that are due to rapid growth
- center of the fibroid becomes red –> causes pain
- AKA: red degeneration
What is the leading indication for a hysterectomy in the US?
-leiomyomata
What is the most common presentation of leiomyomatas?
- menorrhagia or excessive bleeding during menses
- this is probably due to increased endometrial surface are or the disruption of normal hemostatic mechanisms that occur during menses
Degeneration of leiomyomata into leiomyosarcoma?
- rarely occurs
- rapid growth (increase of more than 6wks gestation in 1yr) can be a sign of this process
- history of radiation to the pelvis can be a risk factor
What is seen on PE of a typical uterine leiomyomata?
-irregular midline mass, that is firm, nontender, and moves contiguously with the cervix
Tx options for leiomyomata?
- Medical w/ NSAIDs, progestin, or GnRH agonists tx –> can decrease the fibroid’s size, but the fibroid will return to pre-tx size if tx is stopped
- usually used while correcting anemia prior to surgery - Hysterectomy = proven tx for any women not desiring future pregnancy
- Uterine artery embolization = results in fibroid infarction –> long term results are not promising
- Myomectomy = tx of choice for women who still desire future pregnancies
Cardinal ligament?
- attaches the uterine cervix to the pelvic side walls
- the uterine arteries transverse through here
Intravenous pyelogram?
-Radiologic study in which IV dye is injected and radiographs are taken of kidneys, ureters, and bladder
What is the most common location for ureteral injury in pelvic surgeries?
-at the cardinal ligament
Tx if IVP shows possible obstruction with hydronephrosis and/or hydroureter?
- Antibiotic tx
- Cystoscopy to attempt a retrograde stent passage (this is done in hopes that the ureter is just kinked and not occluded)
What can overdissection of the ureter during pelvic surgery lead to? Ssx?
- devascularization injury to the ureter
- Ssx: nausea and vomiting (bc the urine that leaks into the abdominal cavity causes irritation to the intestines)
Constant leakage of urine out of the vagina after pelvic surgery?
-think: vesicovaginal fistula
Flank tenderness and fever after a hysterectomy or oophrectomy?
-think: ureteral injury
Cystocele?
-bladder bulges into the anterior vagina
Genuine stress incontinence?
-incontinence through the urethra due to sudden increase in intra-abdominal pressure, in the absence of bladder muscle spasm
What 3 things is overflow incontinence usually associated with?
- DM
- Spinal cord injuries
- LM neuropathies
Cystometric evaluation?
- investigation of pressure and volume changes in the bladder with the filling of known volumes
- used to discern btwn stress and urge incontinence
Midurethral sling procedure: what is it? Two types?
- supports the mid-urethra w/ hammock-like effect
- 2 types:
1. Transvaginal tape (TVT)
2. Transobturator tape (TOT)
Transvaginal tape procedure?
- TVT
- minimally invasive procedure used to fix the proximal urethra retropubically via a blind technique using a special hook-like instrument to place a synthetic tape under the urethra
Transobturator tape procedure?
- TOT
- minimally invasive procedure
- similar to TVT, but originates more laterally to try to avoid bladder and bowel injuries that can occur with TVT
Mechanism of genuine stress incontinence?
- normally the bladder and the proximal urethra are both located intra-abdominally, so when there is an increase in intra-abdominal pressure, it is exerted on both and their pressures are equal
- in stress incontinence, something happens (trauma, childbirth, etc) to cause the urethra to fall i to the pelvic cavity and now any increases in intra-abdominal pressure will be exerted unequally and the bladder P > proximal urethra
Best tx for urge incontinence?
- anticolinergic medications
- relax the overactive detrusor muscles
Cystitis?
- Bacterial infection of the bladder
- >100,000 colony-forming units of a single pathogenic organism on a midstream urine sample
Urethritis?
- infection of urethra
- most commonly caused by chlamydia
Urethral syndrome?
- urgency and frequency caused by urethral inflammation of unknown etiology
- urine cultures are negative
What are the 3 reasons why UTIs are more common in oregnancy?
- Incomplete emptying of bladder
- urethral obstruction
- Immune suppression
3 Most common ssx of lower UTI?
- Dysuria
- Urgency
- Urinary frequency
What should gross hematuria make you suspicious of?
-nephrolithiasis
What med is typically not used to tx UTIs bc of E. Coli’s resistance?
-ampicillin!
Tx of mild pyelonephritis in nonpregnant women?
- Trimethoprim/sulfa
- Floroquinolone
- either for 10-14 days
- reexamine pt w/in 48 hrs!!
Tx for pyelonephritis in pregnant women, patient’s with more severe infections, or those who cant take oral meds?
- Hospitalization
- IV antibiotics of either amp & gent or a cephalosporin
- Tx pregnant women with antimicrobial tx (ex nitrofurantoin) for duration of pregnancy once cured of pyelo
5 Most common bacterial causes of UTI?
- E. Coli
- Enterobacter
- Klebsiella
- Pseudomonas
- Proteus
What should be suspected in a pt with ssx of UTI, but negative cultures?
-urethritis caused by chlamydia and/or gonorrhea
What group of nonpregnant women has a high incidence of asymptomatic bacteriuria?
-women with sickle cell trait
Which ectopic pregnancies can be tx with IM methotrexate?
-asymptomatic & small < 3.5 cm
2 Tx for nonviable intrauterine pregnancies?
- D&C
2. Vaginal Misoprostol
Next step when hCG is above threshold, but there is no IUP on US?
- laparoscopy is done to look for and tx ectopic pregnancy
- methotrexate is not used, bc there is a small chance that an IUP can be present
Nontreponemal tests?
- Nonspecific antitreponemal antibody test, such as the Venereal Disease Research Laboratory (VDRL) or the Rapid Plasma Reagin (RPR) tests
- titers fall with effective tx of syphyllis
- if these are negative and suspicious chancre is present, do a darkfeild test to look for spirochetes from scrapings of ulcer
Specific serologic tests?
- antibody tests that are directed against the treponemal organism
- 2 types:
1. MHA-TP (micro-hemagglutinin antibody against treponema pallidum)
2. FTA-ABS (fluorescent-labeled treponemal antibody absorption tests) - these tests will remain positive for life after an infection!
What are the 2 most common causes of vulvar ulcers in the US?
- Herpes simplex
2. Syphilis
What is the most prevalent STI in the US?
-herpes simplex!
Primary syphilis?
- chancre occurs about 3 wks after infection
- will disappear after 2-6wks without tx
- nontreponemal tests may not be present at this time, so do a darkfeild test if they are negative and chancre is still present
Secondary syphilis?
- systemic
- usually occurs about 9 wks after primary chancre
- classic macular papular rash that can occur anywhere on the body, but most commonly seen on palms and soles
- or a flat conylomata lata can be seen on the vulva during this stage
- lesions have high concentration of spirochetes
Tx of syphillis: drug of choice? What if they are allergic? What if they are pregnant?
- treatment of choice = IM penicillin
- allergic = oral erythromycin or doxy
- pregnant = must give penicillin to prevent congenital syphillis! Have to desensitize if the pt is allergic!
Tx of chancroid?
- Oral azithromycin
2. IM ceftriaxone
RPR titers that fall abruptly with tx and then suddenly rise?
-think: reinfection with syphilis!
PRP and SLE?
-can cause false positives in the titers, but the titers would remain constant and not fluctuate
When a pt is tx for syphillis and their RPR titer does not fall?
- think: neurosyphilis!
- can be dx via lumbar puncture!
Dx of neurosyphilis?
-lumbar puncture!
Climacteric?
-perimenopause state
Dx of perimenopausal state?
-elevated FSH and LH levels
When does perimenopause usually occur?
-ages 40-51
Average age of onset of menopause?
-age 52
Tx for hot flashes?
- estrogen replacement
- make sure to give progestin too if the woman still has her uterus!! Bc unopposed estrogen can put her at an increased risk for endometrial cancer
Raloxifene: what is it? Tx of hot flashes?
- selective estrogen receptor modulator (SERM)
- DOES NOT tx hot flashes!!
- can be used to help prevent bone loss though
Premature ovarian failure?
- cessation of ovarian function due to atresia of follicles PRIOR to the age 40
- when it occurs at ages < 30, consider autoimmune diseases or karyotypic anomalies
What do the decreased levels of estradiol in menopause cause?
- Vaginal atrophy
- Bone loss
- Vasomotor symptoms
What is the best tx for osteporosis prevention?
- estrogen, but has risks!
- SERM can be useful in pts who cant or wont take estrogen
Short term estrogen replacement?
- less than 6 mnths
- no evidence of adverse effects
- used for acute relief of menopausal sx
FSH and estrogen replacement tx?
-cant use FSH levels to titrate the dose bc FSH is inhibited by inhibin, NOT estrogen, so it will still be high even with estrogen tx
What do pts with PCOS have excess of?
-estrogen!
What mechanism causes excessive exercise to cause amenorrhea? What tx are these pts given?
- excessive exercise can cause hypothalamic dysfunction = hypoestrogen
- weight gain will often help to resume menses
- pts are often given OCPs to help increase estrogen to prevent effects of hypoestrogen (osteoporosis, etc)
What is the most common location of an osteoporosis-associated fracture?
-thoracic spine compression fracture
What is the risk of continuous estrogen-progestin tx?
-small risk of Cv dz and breast cancer
At how many weeks gestation is the uterus usually at the level of the umbilicus?
-20 wks!
Alpha-fetoprotein?
- a glycoprotein made by the fetal liver
- analogous to the adult albumin
9 Causes of elevated MSAFP?
- Underestimation of gestational age
- Multiple gestations
- Neural tube defects
- Abdominal wall defects
- Cystic hygroma
- Fetal skin defects
- Sacrococcygeal teratoma
- Decreased maternal weight
- Oligohydramnios
What PAPP-A level, free beta-hCG, and nuchal translucency results typically suggest Down syndrome?
- decreased PAPP-A and beta-hCG
- thickened NT
5 Causes of low MSAFP?
- Overestimation of gestational age
- Chromosomal trisomies
- Molar pregnancy
- Fetal death
- Increased maternal weight
What is the window where serum screening for pregnancy can be done?
-btwn 15-21 wks!
What are 4 risks associated with an increased msFAP
- stillbirth
- growth restriction
- preeclampsia
- placental abruption
When does mastitis typically present?
-3rd or 4th week postpartum
What does fluctuance in an are a of the breast suggest?
-abcess, needs to be incised and drained
Mastitis?
-infection of breast parenchyma that is typically caused by staph aureus
Galactocele?
- noninfected collection of milk due to a blocked mammary duct
- causes a palpable mass, breast pressure, and pain
Common tx of mastitis?
- dicloxacillin
- and encourage continuation of breast feeding
Galactocele tx?
- usually resolves on its own
- may require aspiration
Tx of cracked nipples?
- air-drying
- avoidance of harsh soap
Breast engorgement ssx?
- pain/tenderness
- fever (that does NOT last more than 24hrs!)
Suspicious mammographic findings?
-small cluster of calcifications or masses with ill-defined borders
Palpable breast mass with normal mammogram?
- still do biopsy!
- if pt is young, fine needle bx ok, if old do excisional bx (take more tissue when there is more risk)
What is the most common histological subtype of breast cancer?
-infiltrating intraductal carcinoma
Dominant breast mass?
-3 dimensional mass that, on palaption, is felt to be separate from the remainder of the breast tissue
What is the most important risk factor with breast cancer?
-age!
What should be done when the fluid extracted from a breast cyst is straw-colored? Bloody?
- straw-colored = discard fluid, no other follow-up needed
- bloody = send fluid for cytology
Inheritance of BRCA mutations?
-autosimal dominant!!
Unilateral serosanguineous nipple discharge?
-most commonly caused by intraductal papilloma
What should be done with a breast mass that persists after aspiration?
-bx it!
Describe a fibroadenoma breast mass?
- firm
- nontender
- rubbery
- dont change with menstrual cycle
Dx of fibroadenoma?
-in a young pt with no family hx a FNA is sufficient
Fibroadenoma?
- benign
- smooth muscle tumor of the breast
- usually occurs in young women
Fibrocystic breast changes in pre and post menopausal women?
- common in premenopause
- uncommon in post!
Fibrocystic breast changes: presentation? Cause? Dx?
- most common benign breast change
- multiple, irregular, lumpiness of breast
- cyclic(just before menstruation), painful, engorged breasts
- can sometimes have serous or green discharge
- caused by an exaggerated response to ovarian hormones
- can be dx clinically, but a FNA should be done to rule out other causes
Fibrocystic breast changes tx?
- decreasing caffeine ingestion
- NSAIDs
- tight fitting bra
- oral contraceptives
- oral progestin tx
Most common cause of dominant breast mass in a an adolescent-20 yr old female?
-fibroadenoma
Triple assessment?
- Clinical exam
- Mammogram
- Histology
- if they all agree when using FNA or core biopsy, then the results are highly reliable, if not, then more tissue should be sampled
Serosanguineous?
- = bloody
2 Most common cause of unilateral serosanguineous nipple discharge in the absence of a breast mass?
- intraductal papilloma
- Malignancy
* *so do some ductal exploration for dx!
Intraductal papilloma: what is it? Who is it commonly seen in? Cause? Risk factors?
- small, benign tumors that grow in the milk ducts
- most commonly seen in ages 35-55
- causes and risk factors are unknown
2 Tx options of severe cases of fibrocystic breast changes?
- Danazol = weak antiestrogen and androgenic compound
2. Masectomy
Tx of gonorrhea?
- Ceftriaxone IM
2. Azithro or doxy bid for 7-10 days (to tx any concurrent chlamydia)
Why is postcoital spotting often a ssx of gonorrhea/chlamydia?
-both have propensity for cervix and cause irritation of cervix and friability
Acute salpingitis?
-AKA PID
Molecular bio of gonorrhea?
-gram-negative intracellular diplococci
What is the most common cause of septic arthritis in young women in the US?
-Disseminated gonorrhea!
Most common cause of mucopurulent discharge?
-chlamydia!!
Most common cause of sexually transmitted pharyngitis?
-gonorrhea
Secondary amenorrhea?
-absence of menses for a period of 6 mnths or more in a woman has had spontaneous menses in the past
Intrauterine adhesions dx?
- hysterosalpingogram = most common method
- sonihysterography can also be used
- hysteroscopy = gold standard
Tx for Asherman’s?
-Operative hysteroscopy to reduce some of the adhesions
Primary amenorrhea?
-no breast development by age 16
Androgen insensitivity?
-androgen receptor defect in which 46 XY individuals are phenotypically female with normal breast development
Mullerian agenesis?
- congenital absence of development of the uterus, cervix, and fallopian tubes
- 46 XX female
- primary amenorrhea
Pubic and axillary hair in androgen insensitivity and mullarian agenesis?
- androgen insensitivity = scant or absent, bc androgens are responsible for both
- mullerian agenesis = present, androgen is present and active
Gonads in androgen insensitivity v mullerian agenesis?
- androgen insensitivity = testes –> must remove after puberty to prevent malignancy
- mullerian = ovaries are present bc they are not mullerian structures!
What is a pelvic kidney usually associated with?
-mullerian agenesis
Kallmann syndrome in females?
- Delayed puberty
- Lack of breast development
- Normal karyotype
- Inability to smell
Sheehan syndrome?
- hypotension in the postpartum period (usually due to pp hemorrhage) –> hemorrhagic necrosis of anterior pituitary
- anterior pituitary no longer can function = lack of prolactin and amenorrhea
Postpartum amenorrhea?
- amenorrhea for 2-4 mnths usually after a term delivery
- breast feeding may inhibit hypothalamic fctn for longer = longer period of amenorrhea
- nonlactating women usually resume menses in 12 weeks after delivery
Sheehan syndrome tx?
- Thyroxine
- Cortisol
- Mineralocorticoid
- Estrogen
- Progestin
* *replacement tx
Anemia in pregnancy?
-Hb < 10.5
Thalassemia?
- decreased production of one or more of the peptide chains that make up the globin molecule
- most common are alpha and beta chains
- can result in ineffective erythropoiesis, hemolysis, and varying degrees of anemia
What is the most common cause of anemia in lregnancy?
-iron deficiency
2 Most common causes of microcytic anemia?
- Iron deficiency
2. Thalassemia
What is the most common cause of megaloblastic anemia in pregnancy?
-folate deficiency
Wound dehiscence?
- separation of part of the surgical incision
- peritoneum is still intact
Fascial disruption?
- separation of fascial layer
- usually leads to communication of peritoneal cavity and skin
Serosanguineous?
-blood-tinged drainage
Evisceration?
- disruption of ALL layers of the incision w/omentum or bowel protruding through the incision
- surgical emergency!
- can lead to sepsis!
Surgical site infection?
- infection related to the operative procedure that occurs at or near the surgical incision w/in 30 days of an operation
- deep incision = involves deep sift tissue, such as fascia or muscle
What 9 things is fascial disruption often seen more commonly with?
- Vertical incisions
- Obesity
- Intra-abdominal distension
- Diabetes
- Exposure to radiation
- Corticosteroid use
- Infection
- Chronic Cough
- Malnutrition
Evisceration tx?
- sponge that is wet with saline should be placed over the bowel & pt should be taken to OR
- antibiotics should immediately be given!
What is fascial disruption most often caused by?
-the suture tearing through ghe fascia
When does fascial disruption usually occur? Tx?
- 5-14 days postop
- immediate repair and broad spectrum antibiotics
What can be used to distinguish btwn lymphatic fluid and urine?
-creatinine
Copious amounts of sero-sanguinous fluid draining from an abdominal incision?
-think fascial disruption!
What is a superficial wound separation usually due to? Tx?
- hematoma or infection
- tx = open wound & use wet-to-dry dressing
What thyroid dusease can cause galactorrhea? How?
- hypoTH
- increase in TRH –> acts as a prolactin-releasing hormone –> hyperprolactinemia –> galactorrhea
5 Causes of galactorrhea?
- Pituitary adenoma
- Pregnancy –> ALWAYS do pregnancy test
- Breast stimulation
- Chest wall trauma
- HypoTH
Prolactin and GnRH?
-prolactin inhibits hypothalamic GnRH pulsations –> oligomenorrhea
How can galactorrhea be confirmed?
-smear it on a microscope slide, you will see multiple fat droplets
What is the best test for pituitary adenomas?
-MRI
Where is prolactin secreted from?
-ANTERIOR pituitary
2 Posterior pituitary hormones?
- Oxytocin
2. ADH
What is the biggest worry with hyperprolactinemia?
-hypoestrogenemia –> osteoporosis!
Hirsutism?
-excess male pattern hair in a female
Virilisim?
- androgen effect other than hair pattern
- ex cliteromegaly,male balding, deepening of voice, acne
Hirsutism with high testosterone? High DHEA-S?
- testosterone = think androgen-secreting ovarian tumor
- DHEA-S = think adrenal process (adrenal hyperplasia or tumor)
7 Causes of hirsutism?
- Anovulation
- Late-onset adrenal hyperplasia
- Androgen-secreting tumors (adrenal or ovarian)
- Cushing disease
- Medications
- Thyroid disease
- Hyperprolactinemia
Isosexual precocious puberty with an adnexal mass?
- think: granulosa cell tumor
- isosexual = no virilization
Isosexual?
-no virilization
Tx for infertility with PCOS?
-Clomiphene citrate
Rapid onset of hirsutism or virilization?
-think: androgen-secreting tumor
5 basic factors to examine in infertility?
- Ovulatory
- Uterine
- Tubal
- Male factor
- Peritoneal factor (endometriosis
* *cervical factor is rare
3 Ds of endometriosis?
- Dysmenorrhea
- Dyspareunia
- Dyschezia
Infertility?
-inability to conceive after 1 YEAR of unprotected intercourse
Probability of achieving pregnancy w/in one menstrual cycle? Within one year?
- One cycle: 20-25%
- One year: 90%
- *in NORMAL couples
What is the easiest and cheapest way to detect ovulation?
-basal body temp (BBT) chart
What test should be done to look for uterine causes of infertility?
- hysterosalpingogram (HSG)
- dhould be performed btwn days 6-10 of cycle
What is the gold standard for detecting tubal disease?
- laparoscopy
- HSG can be done too, but not as acurate
When should a cervical factor for infertility be considered? Tx?
- when there is thick viscid cervical mucus before ovulation
- intrauterine insemination can be used to bypass the cervix
What is the gold standard for d of endometriosis?
-laparoscopy
Dx if lichen sclerosis?
-bx to confirm clinical suspicion
Location effected in lichen sclerosis v lichen planus?
-planus involves the vagina and LS does not
Lichen sclerosis?
- chronic, inflammatory dermatologic disease characterized by puritus and pain
- mainly affects anogenital region
Lichen sclerosis: typical age of onset?
-postmenopause, but can be at any age
Tx if lichen sclerosis?
- corticosteroids
- avoid scratching
- wear cotton underwear
- avoid irritants
What can occur if lichen sclerosis is left unchecked and w/ repeated scratching?
-can lead to carcinoma of vula!
Group A Strep toxic shock syndrome?
- rapidly progressing infection of episiotomy or c-section delivery incisikn
- “flesh eating bacteria syndrome”
First ssx of septic shock?
-decreased urine output
What is a sunburn-like rash and/or desquamation typical for?
-staph aureus infections
Cystic teratoma?
-benign germ cell tumor that may contain all 3 germ cell layers
Struma Ovarii
- benign cystic teratoma containing thyroid tissue
- can cause sx of hyperTH
Epithelial ovarian tumor?
- neoplasm that arises from the outer layer of the ovary
- can imitate the epithelium of the other gynecologic or urologic system
- most common type of ovarian malignancy
- occurs in older women
Functional ovarian cyst?
- physiologic cysts of ovary
- occurs in reproductive-aged women
- follicular, corpus luteal, or theca lutein in origin
Germ cell malignancy presentation?
-pelvic pain caused by rapidly enlarging pelvic mass
Most common type of ovarian teratomas?
-mature benign cystic teratomas = dermoid cysts
When are dermoid cysts most commonly seen?
-20-30s
Dx of dermoid cyst?
- ultrasound
- see hypoechoic area with fat/fluid level
What is the most common complication of dermoid cysts?
- torsion!
- most commonly seen during pregnancy
- rupture is rare, but presents as shock or hemorrhage
What do immature teratomas contain? When do they usually occur?
- all 3 germ layers and immature or embryonic structures
- usually occur ages 10-20s (dont really occur after menopause)
Immature teratoma tx?
- unilateral salpingiooophorectomy if stage 1
- stage 2/3 requires chemo too
What are mature benign teratomas made of?
- AKA dermoid cysts
- usually ectoderm derivatives (skin, hair follicles, sebaceous glands, sweat glands)
- also contain immature neural tissue elements –> staging is determined by amnt of neural tissue
- can contain all 3 lyrs though
Dx of struma ovarii?
-MRI shows complex multilobulated masses w/thick septa (might represent multiple lg thyroid follicles)
Tx of struma ovarii?
-cystectomy or salpingo-oophorectomy
What are the most common ovarian tumors in women over 30 yrs?
-epithelial ovarian tumors
What are the two types of epithelial tumors?
- Serous type
2. Mucinous type
What characterizes mucinous epithelial tumors? What happens is they rupture?
- their large size
- contain mucinous material that if ruptured can spill into intra-abdominal cavity and cause pseudomyxoma peritonei
What tumor marker can be elevated in epithelial ovarian tumors?
- CA-125
- marker is more specific in postmenopausal women bc it can be elevated for other reasons during reproductive yrs
Tx of epithelial ovarian tumors?
-surgery for staging + chemo
What is the size cut-off that should be used for suspicion of adenexal masses during the reproductive years?
- 8 cm
- > 8 cm warrants investigation!
Appearance of granulosa-theca cell tumors on US?
-solid
Appearance of sertoli-leydig cell tumors on US?
-solid
Tx of dermoid cyst?
-cystectomy
What are usually the largest ovarian tumors?
-mucinous tumors!
Most common ovarian tumor in a woman > 30 yrs & < 30 yrs?
- > 30 = epithelial tumor
- < 30 = dermoid
What size adnexal mass in a postmenopausal woman should be removed and worked up?
-anything 5 cm or more!
What size adnexal mass should be removed and worked up in a prepubertal girl?
-anything 2 cm or more!
What is a common sign of ovarian malignancy?
-ascites
What is the most common etiology of endomyometritis?
-ascending infection if vaginal organisms
Most common cause of fever after c-section when no other cause can be found?
-endomyometritis
Febrile morbidity?
-temp > 100.4F or 48C taken on 2 occasions 6hrs apart within the first 24hrs after a c-section
Endomyometritis?
-infection of the decidua, myometrium, and sometimes parametrial tissues
Septic pelvic thrombophlebitis? Ssx?
- AKA: SPT
- bacterial infection if the pelvic venous thrombi, usually involves ovarian vein
- may have hectic fever, but look well
- may have palpable pelvic mass
Ssx for endometritis?
- uterine tenderness
- foul-smelling lochia
Tx of endometritis? What is no response in 48hrs?
- tx: gentamicin and clinda
- add ampicillin for enterococcus coverage if there is no response after 48hrs
Ddx if postpartum fever?
- Endomyometritis
- Pulmonary etiology (atalectasis)
- Pylenephritis
- Mastitis
- Wound infection
- Endometritis
- Septic pelvic thrombophlebitis (rare)
Endometritis more commonly follows what type of delivery?
-C-section
What is the most common type of bacteria that causes endomyometritis?
- anaerobic bacteria
- most common species = bacteroides
Tx of septic pelvic thrombophlebitis?
-antibiotics + heparin
Dyspnea and tachypnea while undergoing tx for pyleonephritis?
- think: ARDS –> due to pulmonary injury from endotoxin release
- endotoxins are released with the lysing of the bacteria by the antibiotics
- endotoxins can cause damage to myocardium, liver, kidneys and lungs via causing leaky capillaries
Tx of ARDS?
- Supplemental oxygen
- Monitoring if fluids (DONT overload)
- Supportive tx
What is the most common bacterial cause of pyelonephritis?
-E coli
Acute Respiratory Distress Syndrome (ARDS)
- AKA: ARDS
- alveolar and endothelial injury that leads to leaky pulmonary capillaries
- causes hypoxemia, large alveolar-arterial gradient, and loss of lung volume
What is the most common cause of sepsis in a pregnant woman?
-pyelonephritis
Tx of acute pyelonephritis in a pregnant woman?
- Hospitalization
- IV antibiotics (cephalosporins, or combo of amp +gent)
- Tx until fever and flank tenderness is main,y gone then switch to oral tx
- Suppressive tx for remainder of pregnancy
What should be suspected if clinical improvement has not occurred after 48-72 hrs if proper tx of acute pyelonephritis in a pregnant woman?
- Urinary tract obstruction (ex ureterolithiasis)
2. Perinephric abscess
What is seen on chest xray in ARDS?
- diffuse bilateral or interstitial infiltrates
- but may be normal if early
Pelvic inflammatory disease?
- AKA salpingitis
- infection if fallopian tubes
Cervical motion tenderness?
- extreme tenderness when cervix is manipulated
- suggests salpingitis
- AKA “chandelier sign”
Tubo-ovarian abcess?
- AKA: TOA
- collection of purulent material around the distal tube and ovary
- does NOT require drainage, can be tx with antibiotic tx
- can be a sequelae of salpingitis
Dx of acute salpingitis?
- clinical dx made by presence of:
1. Abdominal tenderness
2. Cervical motion tenderness
3. Adnexal tenderness
Tx of acute salpingitis?
- if pt is stable enough to be tx outpatient = single Im dose of ceftriaxone or oral doxy 2x day for 10-14 days
- inpatient = IV cefotrtan or IV doxy
IUD & OCPs and risk of PID?
- IUD increases the risk of PID bc breaks the endocervical barrier as it enters the uterus & can spread any infection from the endocervix into the tubes
- OCPs decrease the risk of PID bc the progestin thickens the cervical mucus
Gold standard test for dx of salpingitis?
-laparoscopy
Cause of PID that causes sulfur granules on the fimbria?
-actinomyces!
