OBGYN mix UWQ : june 28th 2021 Flashcards
McCune -Albright syn
sym?
triad:
- > cafe au lait spots
- > polyostotic fibrous dysplasia
- > autonomous endocrine hyperfunction
—> GnRH -ind precocious puberty
—-> early puberty
Routine prenatal lab screening ?
initial prenatal visit:
- RH (D) type, AB screen
- Hbg / Hct, MCV
- HIV, VDRL/RPR ( SYPHILIS) HBsAg
- Rubella + varicella immunity
- Pap test (if needed)
- Chlamydia PCR + neisseria gonorrhea
- Urine Pn + culture
—-> inactivated influenza vaccination : safe every trimester + breastfeeding !!
wk: 15-20
- > trisomy testing: MS-AFP, b-HCG, Estriol, Inhibit-A :
- > cell -free fetal DNA testing : circulating, free maternal , fetal DNA in mat plasma
- > trisomy 13, 18, 21
- > SMA !!!!
24-28 wks: Beginning 3rd trimester
- Hbg/ Hct
- AB Rh(D) -
- 50g 1 hr Oral glc challenge test
- REPEAT: HIV, Syphilis, Gonorrhea, Chlamydia , HBV
35-37 wks:
- -> GBS culture
- -> rx: Intrapartum penicillin !!
** LEAD exposure: house < 1978!!!
missed abortion
sym?
lab?
rx?
<20 wks gestation
- > expulsion products
- > ASX / dec pregnancy sym
- > CLOSED CERVIX
- > NO BLEEDING!!
- > NO fetal cardiac
risk factor: spontaneous abortion
-> adv maternal age : inc chrm abnormalities
dx:
-> u/s : EMBRYO w/o cardiac activity / empty gestational sac w/o fetal pole (NO embyro)
- –> normal inc b-HCG till end of 1st trimester
- -> dec b-HCG : demise !!!
rx: MISOPROSTOL : dilation + myometrial contraction to expel IU content : labor induction
hydatidiform mole
lab?
- > snowstorm appearance
- -> heavy vag bleeding
- > enlarge uterus + HETERGENOUS cystic mass
- > b-HCG >100,000 IU/L !!!
- > elev T3, T4 : hyperthyroidism !!!
rx:
- -> SUCTION CURETTAGE !!!
- > hysterectomy
f/u: b-HCG level
risk :
- > Vit A def ( Roux-en-Y sx)
- > adv age >40
incomplete abortion?
< 20 wk GA !!!
- > PAINful!!!!
- > BLEEDING
- > DILATED cervix , -> SOME passage of products
threatened abortion ?
- > vaginal BLEEDING
- > CLOSED CERVIX
- > fetal cardiac activity: + NORMAL IU Gestation !!
—> asso with subchorionic hematoma : abnormal collection blood btwn placenta + uterus
vulvar lichen sclerosus
sym?
dx?
rx?
- > PREpuberty girls + peri-menopauseal / post-menopause
- –> asso : alopecia areata
sym:
- > THIN WHITE wrinkled skin LABIA PLAQUES , atrophic extend over perineum + anus ( clitoral HOOD retraction)
- -> adherence at labia at midline
- > EXCORIATION , erosion , fissure from severe pruritus
- > dysuria , dysparenunia, painful defecation
- ** NOT affect VAGINA***
dx:
- > punch biopsy r/o Ca ( elderly)
rx: steroids ointment
- –> CLOBETASOL
ectopic pregnancy
sym?
- -> cornual ectopic
- > hemodyn unstable : ruptured ectopic pregnancy
—> unilateral pain + light vag bleeding
dx: U/S COMPLEX adnexal mass !!!
–> D&C : sample w/in endometrial cavity
postprocedure b-hcg level
——> neg / dec b-HCG : confirms abnormal IUP : observe + reassurance
—-> persistent rise b-HCG s/p D&C: ectopic preg
rx:
stable: MTX!!!
- -> continue monitoring b-HCG level till become undet
unstable: ER sx exploration!!!
- —> if pt has IUD : CONFIRM with TVUS to locate intra/ extrauterine pregnancy?
- > if intrauterine : REMOVE IUD !!
breech presentation
rx?
- -> > 36 wk
- -> Ext cephalic version !!!
–> vaginal delivery if successful : FRANK/ COMPLETE BREECH
!!! CONTRA vag delivery:
- > INCOMPLETE BREECH/
- –> FOOTLING
!! —-> PRIOR C/S delivery !!
- -> placnta previa
- > prior ext uterine myomectomy
inc risk:
- > PROM
- > abruptio placentae
- > preterm labor
RF:
- > adv age > 35 yr
- > fibroids
- > uterine didephys, septate uterus
- > fatal anomalies
- > preterm < 37 GA
- > oligo/ poly- hydramnios
- > placenta previa
internal PODALIC version
useage?
TWIN delivery
menopause
rx?
HRT: prevent
—> VASOMOTOR symptoms !! Hot flashes, night sweat, sleep disturbance
** not recommend: osteoporosis / CVD prevention! inc risk of thromboemboli
-> vag atrophy : pruritus, dryness, irriation
-> dysparenunia
!!!! -> Urinary incontinence , recurrent UTI
-> pelvic pain
-> hyperestrogenism
hx: Low estrogen: loss epi elasticity!!
- > vag PETECHIAE, vest FISSURES !!!
* * NOT cause white PLAQUES!! / NOT inv perianal region !!!
dx:
- > clx
- > elev vaginal PH > 5 !! –> inc risk of UTI !!!
rx: mod - severe vasomotor syn:
INTACT UTERUS: Menopausal hormone therapy : E + P : inc risk breast Ca long term use
NO uterus : ESTROGEN only MHT ( transdermal estrogen patch)
–> contra to E patch : breast Ca, venous throboembolism , CVD, endometrial ca
—> switch rx: SSRI, gabapentin ( dizziness/ HA), clonidine ( hypotension)
physio pregnancy hydronephrosis ?
physio?
rx?
-> bil kidney enlargement
-> bil dilation renal pelvises + Proximal ureters
MC @ right ureter
- > inc maternal BV
- > req inc renal filtration : greater renal vasculature + int tix
-> begins 1st trimester
: high P level –> Ureteral DILATION + dec peristalsis
rx: NO additional rx
*** uretheral stents + nephrostomy tube: ureteral blockage ( nephrolithiasis) !!–> microscopic hematuria + unilateral image (stones)
endometriosis
sym?
rx?
- –> ectopic implant endometrial glands ( UNILOCULAR adrexal gland!!!)
- —> lat displacement of cervical
- > dysmenorrhea
- > DEEP DYSPAREUNIA
- > chronic pelvic pain: throughout the MENSES !!!
- —–> infertility
- > dyschezia
- > cyclic dysuria !!!!
- > hematuria
PE:
- > post cul-de -sac !!!! , retrovag septum
- > immobile uterus
- > cervical motion tenderness !!!!
–> bladder : bladder pain, supra-pubic tenderness , bladder inflammation
hx: HOMOGENOUS . low level echos ( blood)
dx:
TV u/s
-> direct visualization : LP !!!!! surgical biopsy
rx:
AXS: reassure + observe only
Med: Sym pt
OCP, NSAIDS
–> GnRH + ( leuprolide/ lupron ) : E suppression / Testo derivative ( Danzol)
-> surgery resection: LP fulguration of lesions
vaginismus
sym?
rx?
-> Genitopelvic pain / penetration dx
- > dyspareunia
- > pain with ANY vag penetration ( sex, speculum exam!!)
rx: desensitization therapy
kegal exercise
CBT
placenta previa
sym?
rx?
–> placenta covers CERVIX!!!
inc risk:
- > multiparity
- > adv age > 35
- > prior C/S!!! Major risk
- > prior placenta previa
- > multiple gestation
comp:
antepartum hemorrhage
—–> PAINLESS !!!! HEAVY Vag bleeding !!!! w/ or w/o contraction
dx:
-> repeat u.s performed 3rd trimester
rx:
-> pelvic REST !!
routine OB care
C/S > 36-37 wks
contra:
- > Digital cervical exam
- > DRE
Anti-D Ig
given?
postpartum up to 72 hrs
lab:
KLEIHAUER _BETKE TESTING
Coombs test +
—-> hemolytic fetalis
postpartum hemorrhage
> 1000 ml
MCC
rx?
- –> uterine ATONY !!!
- —-> SOFT , boggy, enlarged uterus !!!
- -> fundus ABOVE the umbilicus : DEC uterine tone !!!!
RF:
- –> insufficient uterine contractility
- > uterine fatigue
- > operative vag delivery forceps assisted
- bimanual uterine massage + high dose OXYTOCIN : inc Ca in muscle cell –> inc uterus contraction!
- tranexamic acid : antifibrinolytic : prevent breakdown blood clots to achieve hemostasis : reduce mat mortality hemorrhage
- 2nd line Uterotonic agents:
- > methylergonovine ( se: HTN + inc risk of STROKE !!! potent vasoconstrictor )
- > carboprost ( prostaglandin F2a analog) tromethamine ( se: asthma: bronchospasm !! )
- > misoprostol
—> FFP blood infusion
- IU balloon tamponade
- LP: D&C
gestational HTN –> Preeclampsia with severe syndrome!!!!
dx?
lab?
new onset HTN > 20 wks !!!! SBP > 140 / DBP > 90 -------> inc comp: preterm!!! --> FGR!!! -> fetal OLIGOHYDRAMIOSIS
inc risk:
- –> TWIN preg !!!
- -> type 1 DM
lab:
1. BP measure
2. clx EOF : WORSENING HA!!!! visual change , RUQ pain
3. EO dmage : UA, CR, AST, ALT, PC
4. fetal nonstress test
- —-> UA : high false Neg !!
!!!! GS: 24 hr urine collection total pn!!!
preeclampsia
up to 6 wk postpartum !!
risk?
patho?
rx?
-> abnormal narrowed spiral artery formation : placental hypoperfusion , hypoxia, ischemia —-> endothelial cell damage !!!
!!!! with severe features:
risk: HELLP syn :
-> Liver : stretch hepatic capsule
-> kidney: Pnuria : AKI
-> brain : ACUTE STROKE !!!!
!!! —-> Pt < 100,000
HTN SBP >140/ DBP >90
–> pul edema
——> + coagulation sys + Pt : vascular microthrombi formation –> ischemia STROKE !!
——> dysreg CBF : cerebral vasospasm : inc perfusion pressure : rupture IC vessels : HEMORRHAGIC STROKE !!! HA, visual change
dx:
- -> 24 hr urine total pn collection
- -> CT scan head!!
rx:
- > IV labetalol : fast acting, effective
- -> se/ BRADYCARDIA !!
- > IV hydralazine : direct arterial vasodilator !!
- > oral Nifedipine: CCB
> 37 wks / >34 wk with severe sym: delivery !
SAH
risk?
- > SMOKING
- > chronic HTN
sinusoid fetal HR tracing
?
Category 1: reassuring : low risk fetal hypoxemia + acidemia
Category 3:
> 1 sym:
–> inc risk fetal compromise + req urgent rx
!!!! —> severe fetal anemia : rupture vasa previa !!!!
- –> fetal exsanguination + deterioration
rx: ER c/s
fetal tachycardia > 160/ min !!!
etio?
—-> intraamniotic inf : chorioamnionitis !!!!!
sym?
dx?
rx?
- > FEVER , inc SNS
- > asso prolonged preterm prelabor rupture of membrane (PPROM)!!!
dx: nitrazine + fluid !!!
FEVER + any one:
- > tachycardis,
- > inf
- > purulent AF
rx:
!!! IMMEDIATELY DELIVERY!! + AB ( ampicillin + gentamicin) !!!
–> reduce mat endometritis, neonatal early onset SEPSIS, cerebral palsy
—> if < 34 GA: steroids!!!
—-> if < 32 GA: MgSO4 if preeclampisa
** no need C/S
-> VARIABLE deceleration
etio?
—> UC compression !!!!
—> oligohydramnios
AFI <5 cm
—> cord prolapse
rx:
- -> Maternal repositioning!!
- -> AMINOINFUSION saline: reduce UC compression
mature cystic teratoma ( dermoid cyst)
hx?
sym?
rx?
-> germ cell tumor benign : somatic diff of primordial germ cell
- -> sebaceous fluid, teeth, hair
hx: HYPERECHOIC nodules + Calcification - -> heterogeneous solid + fluid !!!!!
sym: intermittent, colicky pain
- > trigger by phy activity
risk:
- > torsion
- > ischemia / necrosis
rx: LP ovarian cystectomy / oophorectomy
uterine leiomyomas ( fibroids)
sym?
dx?
rx?
-> age < 35 yr
-> IRREGULAR , firm infertility
UTERUS !!!
—-> proliferation SMOOTH MUSCLE w/in myometrium
loc:
1. SUBmocosal : dec fertility + protuding into uterine cavity
—-> se/ compress embryo implantation / growth !
Dec endometrial thickness + reduce vascularity fibroids!
!!!! —> DEGENERATING fibroids : uterine contraction : PROSTAGLANDIN release + fundal tenderness
rx: hysteroscopic MYOMECTOMY ( maintain fertility!! )
2. SUBserosal : enlarge + BULK -> constipation
–> asso w/ : dysmenorrhea
dx: pelvic U/S !!!
rx:
ASX: observe!!!!
sym: HT ( hormonal contraception) : with SYMPTOMS patient
- > Sx
polyhydramnios
etio?
sym?
-> uterine size larger than dates discrepancy !!!!!
AFI > 24
etio:
-> fetal urination + removal imbalance
-> DM !!: fetal macrosomia : inc risk of PROTRACTED LABOR
- > TE fistula
- > IDIOPATIC
- -> cong infection
- -> DM
- > Anencephaly
risk: dyspnea ( mat lung compression) : < 37 wks : rx/ Betamethasone !!!
- > abd pain ( inc uterine size)
- > preterm contraction ( inc IU pressure)
- > PROM
- > UC prolapse
- > preterm labor
- > malposition fetus
rx: mild / ASX
- –> amniocentesis
- –> expectant management
amenorrhea , insomnia, WG
dx?
–> HCG level!!!!
dec ovarian reserve?
- -> age 35 !!!
- > dec Oocyte # + quality
- > reg MC
lab:
- > dec estradiol, inhibin production
- -> normal neg feedback: suppression –> INC FSH !!!!
primary ovarian insufficiency
sym?
2ndry amenorrhea ( lack MC > 6 mo with previous irregular cycles)
menopause before <40 yr !!
- > HOT flashes
- > Amenorrhea
- > Vag atrophy
- > Osteoporosis
- > CAD
lab:
- > Inc FSH, LH !!
- > dec ESTROGEN
- -> LACK progesterone progesterone challenge test : NO slough off
inc risk:
-> FMR1 premature carriers
( mRNA over-expression: cytotoxic effect on ovarian primordial follicles -> accelerate follicle depletion
-> TS
—> CMT + radiation rx: target dividing cancer cells
rx: Estrogen containing rx to red ostoporosis , CVD
fetal hydrops
sym?
patho:
- > inc cardiac Output demand –> HF ( bradycardia)
- > inc fluid movement –> interstitial space ( 3rd spacing)
sym:
- > pericardial effusion
- > pleural effusion!!!
- > ascites
- > skin edema
- > placental edema
- > POLYHYRDAMNIOS
- —> SLAPPED CHEEK RASH !!!!!
etio:
immune: RhD alloimmune
nonimmune:
- > parvovirus B19 !!!!
- —–> transmit: resp droplets
- > fetal aneuploidy
- > CV abnormalities
- > thalassemia ( Hbg barts) !!!!
recurrent cystitis
rx?
- > > 2 inf / 6 mo
- > > 3 inf / year
risk: sexual active
- > postmeno
- > 1st UTI < 15 yr
- > spermicide use
ppx:
daily AB PPX
-> POSTCOITAL PPX!!!
- *** renal U/S : + urine culture with recurrent cystitis
eg. proteus
bladder Ca
dx?
dx:
cystoscopy
adenomyosis
sym?
etio?
dx?
- > multiparous > 40 yr
- —–> ENDOMETRIAL GLANDS + STROMA win myometrium
sym:
- > HEAVY MC bleeding MC
- —> new onset dysmenorrhea : cyclic shedding
- –> BOGGY, tender UTERUS
- > SYMMETRICALLY enlarged
dx/
- > pelvic u.s
- > MRI
- > hysterectomy
rx: OCP, P-releasing IUD
- > tranexamic acid ( antifibrinolytic agent) !!!!
2ndry amenorrhea >
- > amenorrhea > 3 mo with previous reg MC
- > > 6 mo irregular mc
-> most women return spontaneous MC w/in 1-3 mo cessation OCP
—> HPO axis dysfunction + endo abnormal
dx:
HOP axis: FSH, TSH, prolactin level !!!
—> elev prolactin: f/u MRI
preg Diabetic insipidus ( DI)
sym?
lab?
- > low sp gravity < 1.006
- > polyuria > 3 L UO
- > diluted urine ( water diuresis)
- -> POOR ADH production: unable to inc renal water reabsorption in CT !!!
Pregnancy: placental production enz : vasopressinase : inc ADH breakdown
—> unmasking DI
dx: challenge with desmopressin ( ADH analogue)
gestational DM
sym?
-> polyuria osm diuresis ( excess glc : hyperglycemia / urea : AKI)
–> high sp gravity : conc urine
hyerandrogenism in pregnancy
sym?
etio?
-> acne, male pattern terminal hair
- > maternal: ovarian masses
- > fetal: placental aromatase def
sym:
BIL ovarian masses u/s
etio:
- Luteoma preg:
- -> SOLID, bil mass
- > inc b-HCG: + leuteoma Lutein cells —> inc ANDROGENS release : mat + fetal VIRILIZATION !!! - Theca lutein cysts:
- > CYSTIC , BIL mass
- > elev b-HCG
- > low risk fetal virilization
- —-> Ovarian hyper-stimulation from abnormal trophoblastic proliferation
rx: observe + exp management
resolve after delivery !!!!
Sertoli - leydig tumor
sex cord stromal tumor
sym?
lab?
rx?
RAPID onset !!! <1 yr
+ elev testosterone
—> suppress FSH, LH
*** (congenital adrenal tumor: DHEA > 700 ug/dL )
- > virilization : voice deepening, male pattern BALDING, inc muscle mass, CLITOROMEGALY
- > ESTROGEN DEFICIENCY: oligomenorrhea/ amneorrhea, abnormal uterine bleeding, vulvovaginal ATROPHY!
- > unilateral, solid, COMPLEX MASS
rx: sx
cholelithiasis in preg
patho?
sym?
dx?
rx?
- > inc Biliary chol excretion ( estrogen)
- > dec GB motility ( progesterone)
sym:
- > recurrent, postprandial epigastric / RUQ pain
dx: abd U/S
- > RUQ u/s with echo foci ( stones/ sludge)
rx:
pain control
-> cholecystectomy ( recurrent / complicated)
Gestiatonal thrombocytopenia
sym?
- > ASX
- > MILD red PC 100,000- 150,000
rx: reassurance and observe
epi ovarian Ca
sym? RF? protective factor? lab? dx? rx?
sym:
- > AXS
- > subacute:pelvic/ abd pain . bloating , early satiety
- > acute: dyspnea, obstipation / constipation, abd distension
RF: LONG Estrogen exposure
- > FX
- > BRAC1,2
- > Age> 50
- > HRT
- > endometriosis
- > infertility
- > early menarche/ late menopause
protective:
OCP
multiparity
breastfeeding
dx:
- —> inc CA-125 !
- > u/s : solid , complex mass , THICK SEPTATION, ASCITES
rx: LP + sx staging +/- CMT
obesity + anovulation
sym?
chronic >.6 mo abnormal uterine bleeding –> 2ndry excess adipose tix : OBESITY!!!
+ HPO axis :
- inc insulin resistance + hyperglycemia
- —> dec production SHBG —> elev free androgen level
- —> inc aromatized adipose tix –> ESTRONE (estrogen elev) !!!
high estrone : high freq short interval GnRH pulses : inc LH /FSH ratio imbalance –> ANOVULATION !!!
inc risk: ENDOMETRIAL HYPERPLASIA/ CA !!!!
fetal macrosomia
etio?
- > maternal obesity
- > excessive preg WG
- > GDM
- > post term preg
sign: PROLONGED 1st / 2nd stage labor
- > TURTLE SIGN
- ** uterine fibroids: NOT affect fetal growth
- -> inc risk : miscarriage,, malpresentation , c/s
eclampsia
sym?
HTN + SEIZURE
(GTC)
-> postictal state
: HA, n/v, hyperreflexia, elev CR
** NOT CAUSE FEVER / TACHYPNEA !!
dx: CT scan : bil frontal / occipital lobe EDEMA !!!
- –> inc risk: stroke,
rx: MgSO4 birth < 32 GA !!!
- —> delivery !!
- *** triptan abortive rx: NOT USED during pregnancy!! risk FGR + preterm labor
- -> unilateral throbbing pain
osteoporosis risk factors?
NONmodifiable:
- > adv age
- > postmeno
- > low BW: low bone mass : inc risk fragility fracture !!!
MODIFIABLE:
- > smoking
- > ETHO
- > lifestyle
OCP se?
-> primary dysmenorrhea
—-> rx: OCP : Estrogen- Progestin oral / vaginal ring
se/ n, bloating, breast tenderness
-> breakthru bleeding
- > !!!!! severe HTN : : ABSOLUTE contra in MIGRAINE pt
- > estrogen med inc Hepatic angiotensinogen synthesis + RAS
- > inc risk CERVICAL CA!!!!
- —–> DEC risk: ovarian + endometrial ca!!!!
- > venous Thromboembolism !!!: MI + STROKE !!!!
- > hepatic adenoma !!!
- > inc TG
—> AVOIDED in breast feeding / postpartum < 1 month !!! DVT risk
hypercoagulability
*** WG not asso with OCP!!!!
Medroxyprogesterone ( progesterone) acetate
IM injection
se?
- > inc body fat, dec lean muscle mass
- > WG!!!!
–> DEC bleeding by 50% + amenorrhea in 20%
NOT rx for young aldolescent : sig risk bone mineral density loss!!!
Latent phase : cervical 0- 6 cm
!!! active phase labor 6-10 cm dilation : normally progression > 1 cm / 2 hr !!!!
stages?
etio?
Protraction: cervical change slower than expected +/- inadeq contraction
—–> rx: OXYTOCIN
Arrest:
—> No cervical change > 4 hrs ( < 1 cm/ 2 hr) w/ adequate contraction ( > 200 MV unit in 10 mins)
OR
—> No cervical change > 6 hrs ( < 1 cm / 2 hr) w/ INadequate contraction ( <200 MV units)
rx: C/S!!!!!
etio:
- > uterine : inadeq contraction
- > fetal : malposition, macrosomia, CEPHALOPELVIC DISPORPORTION!!!!!
- -> >41 wks GA
- > pelvis: deformity / fracture
- > maternal obesity , WG, adv age
twin preg
risk?
- > spontaneous PRETERM labor !!!
- -> preeclampsia
- > GFR
- > uterine crowding + uterine over-distension ( uterine size-date discrepancy)
- —> over stretch myometrium: inc prostaglandin +
- –> inc # oxytocin receptor + contractility w/in uterus
- –> abd vasoconstriction + inc pt aggregation
rx: ASA @ 12 wks gestation
fetal dysmaturity syn?
post term > 42 wks gestation
- > age related : infarction , Calcification !!!
- > uteroplacental insufficiency
risk of fetal demise!!!!
cervical insufficiency
RF?
sym?
rx?
RF:
- > Collagen defects
- > Uterine abnormalities
- > Cervical conization!!
- > Ob injury
sym: ≥2 prior painless, 2nd-trimester losses -> PAINLESS cervical dilation -> mild sym with inc Vag discharge , light bleeding, pelvic pressure -> NO uterine CONTRACTION!!
rx:
CERCLAGE:
ind for:
–> cervix < 2.5 cm < 24 GA
or
-> hx of 2nd trimester deliveries !!!
!!!!! PROGESTERONE SUPP:
-> @ term del prior + cervix < 2.5 cm
screening chylamdia + gonorrhea?
MC STD in:
- > age < 25
- > high risk sexual beh !!!!
high prevalence
–> inc risk PID , infertility, ectopic preg , tubal scarring !!!
rcx:
-sexual active women
-> ANNUAL SCREENING!!!
NAAT (GS)
stress urinary incontience ( SUI)
sym?
rx?
-> intermittent involuntary loss urine
-> inc intra-abdominal pressure ( coughing, laughing)
——> dec urethral SPHINCTER muscle tone !!!
+ INSUFFICIENT URETHRAL SUPPORT : urethral HYPER-MOBILITY !!!!! weaken pelvic floor muscle
risk:
obesity, pregnancy, chronic high impact exercise
rx: kegal exercise, pessary , midurethral sling
—> postpartum SUI: self limit < 6 wks
overflow incontience
sym?
rx?
-> CONTINOUS, PAINLESS LOSS URINE
–> diminish / IMPAIR contractility bladder detrusor : neurogenic bladder : DM ( osmotic diuresis)
- > demyelination sacral SC ( cauda equina) : impairment lower motor neuron input to bladder -> detrusor underactivity !
- > chronic urinary retention : elev postvoid residual > 150 mL !!!!
- > ext compression of urethral outlet ( fibroids, prolapse) : BLADDER OUTLET OBSTRUCTION!!!!!
rx:
Cholinergic (bethanechol) : + M receptors to cause bladder contractility
- > Alpha-blocker ( tamsulosin) : BPH for men : relax bladder neck + prostate neck SM
overactive bladder
(URGE) ?
excessive (Overactivity) involuntary detrusor muscle SPASM (
- > sudden urge to urinate
- > immediate loss urine
etio:
- > MS
rx:
- > Anti-Muscarinics: inhibit blasser spasm ( oxybutynin)
- -> promote bladder relaxation
–> Mirabegron : beta -3 -adrenergic agents : + beta receptor in detrusor muscle : SM relaxation
-> time voiding technique
antiphospholipid ab syndrome (APS)
syn?
lab?
rx?
** TRANSIENT ischemic attack: MC APS etio
1 clinical + 1 lab MUST:
clx:
-> vascular thrombosis : Arterial/ venous
- > preg morbidity:
1. > 3 consecutive , un-explain fetal loss < 10 wk
2. > 1 un-explain fetal loss > 10 wk
3. > 1 premature birth before 34 wks due to preeclampsia , eclampsia , placental insuff
lab:
- > lupus anticoag
- > anticardiolipin ab
- > anti-beta -2 glycopn ab
- –> AB cross-reaact with VDRL : false +
rx: LMWH !!!
anovulatory cycles
rx?
unopposed estrogen + : proliferation endometrium
rx: PROGESTERONE help control + stabilize
postpartum lochia?
stages?
dx?
rx?
- lochia rubea: birth - 3/4 days
- –> dark / bright red ; odor similar to menses ; SMALL clots - lochia serosa : s/p 4th - 14 days
- –> Serosanguineous pink; brownish old blood - lochi alba : 11- 6 wks s/p
- -> white / yellow; creamy ; light quality
–> postpartum , endometrial shedding + regeneration : lochia
dx: OBSERVE + reassurance
6-8 wks s/p !!!!
nephrolithiasis
sym?
- > hematuria + WBC on UA
- > colicky pain radiated from flank to pelvis
dx:
renal u/s
rx: pain control
iv hydration
-> complicated : cystoscopy, stent
urethral diverticulum ?
-> herniation urethral mucosa into surrounding tix
- > dysuria
- > postvoid dribbling
- > urethral discharge
- > ant vaginal mass
dx: MRI
rx: surgery excision
vesicovaginal fistula
sym?
dx?
rx?
- -> urinary CONSTANT leaking ANTerior
- > abnormal bladder + vaginal fistulization !!!
etio:
1. intra-operative bladder injury : c/s , hysterectomy
- wk- mo s/p Sx / child birth : ob labor : tix necrosis / sloughing
- pelvic radiotherapy: !!!!! microvascular injury ( endarteritis) , progressive tix ischemia ( raised , RED GRANULATION TIX) + breakdown
dx: bladder dye testing
rx:
sx repair + bladder decompression ( catherterization)
trichomoniasis
Trichomonas vaginalis
sym?
-> thin, yellow-GREEN , Malodorous FROTHY discharge
–> MOTILE , flagellated ovoid protozoa
trichomonads !!! wet mount microscopy
- > vag inflammatory
- > Ph > 4.5
rx: metronidazole
- > rx partner also!! -> etho cessation : disulfiram like rxn
pseudothrombocytopenia
sym?
lab?
dx?
rx?
lab error: pt aggregation in vitro : peripheral BS –> LARGE CLUMPS pt !!!
–> incompletely mixed blood sample / presence Ab EDTA
dx: confirm with : non-EDTA anticoag mising normalizes the automated PC
rx: monitor
primary syphilis
sym?
dx?
rx?
Single, PAINLESS CHANCRE ---> papule , non-exudative ulcer with INDURATED BORDERS !!!!!!!!!!! -> PAINLESS LAD!!!!!! -----> NOT asso with POSTCOITAL BLEEDING / CERVICAL LESIONS!!
—> 2ndry syphilis: condylomata lata
dx:
- NON trep: VDRL + RPR
- Specific trep: FTP-ABS
rx: PNC-G
- —-> pen allergy : desensitized : IM PNC-G benzathine !!
** nonpregnant: DOXYCYCLIN!!! contra : fetal bone growth !!
** azithromycin/ doxycyclin: rx: chlamydia
** neisseria: ceftriaxone
chancroid
sym?
haemophilus ducreyi
- > multiple + DEEP ulcers
- > base gray - yellow exudate
- > organism clump in long parallel strands
- > PAINFUL !!!!
chylamydia trachomatis
sym?
Lymphogranuloma venereum
- > small, shallow ulcers,
- > large, PAINFUL INGUINAL LN ( BUBOES)
- > intracytoplasmic chlamydial Inclusion bodies epi cells + leukocytes
- > not painful lesion !!
rx” azithromycin
breast Ca
BRCA
hypercoagulable dx
contraceptive rx?
–> COPPER IUD
( hormone free)
10 yr duration
** all other hormone -containing contraceptives CONTRA !!!!
estrogen / progesterone
shigellosis
sym?
fever, abd pain, tenesmus
bloody diarrhea up to 7 days
rectus abdominis diastasis ?
stretching abd :
- > wken linea alba , fascia
- > nontender midline mass
- > NO asso fascia defect
- > NO asso pain, acute GI sym / risk strangulation / incarceration
rx: observe + reassure
- > resolve postpartum
postpartum thyroidism
sym?
-> brief hyperthyroid phase release TH -> subseq HYPOthyroidism phase -> hypercholesterolemia -> hypoNa
lab:
- > TSH elev
- > free T4 low
- > anti-thyroid peroxidase autoab
*** adrenal insuff: dec BP
ovarian torsion
sym?
- > adnomyosis inc risk
- > age > 40
- > heavy MC bleeding
- > tender, globular uterus
- –> hix of OVARIAN CYST / mass
sym:
sudden onset , UNILATERAL pelvic pain!!! NON-radiating pain
- > n/v
- > PARTIAL: intermittent adnexal rotation: self resolves + spontaneous adnexal untwisting allows BF to return
- > doppler: normal BF
-> COMPLETE rotation around IP ligament ( ovarian vessels) -> adnexal tenderness / fullness -> peritonitis --> dopples u/s : DEC / absent ovarian BF
rx:
ER LP !!!!
unilat ureter laceration
etio?
-> large intraabd fluid -> watery vaginal discharge
uroperitoneum
-> gyn Sx ( hysterectomy)
——> Ureteral OB + HYDRONEPHROSIS ( nonradiating focal back pain , unilateral CVA tenderness)
URETER vulnerable to injury !!
proximal to ovarian vessels ( Infudibulopelvic / suspensory lig) + UTERINE VESSELS ( near cervix)
lab: normal Cr + UA ( contra kidney normal )
dx:
u/s renal
Ct urograpy
rx: SX repair
intraabd abscess
sym?
high FEVER
leukocytosis
abd tenderness
intraductal papilloma
sym?
rx?
-> benign PAPILLARY tumor arising from breast duct lining
sym:
- > unilateral bloody niple discharge ( nonbloody)
- > no asso with breast mass/ LAD
rx: MAMMOGRAPHY + u/s
_> biopsy + excision !
ductal ectasia
sym?
-> benign brerast duct thickening + dilation –> CLOGs the duct!!!!
- -> bloody nipple discharge, duct widens
- -> buildup fluid
biophysical profile
?
Stress test (heart), lungs, movement, AF voln
Max score = 10
<4 abnormal
—-> fetal HYPOXIA: placenta dysfunction
2 = normal each component
+ OLIGOHYDRAMNIOS ( deepest pocket < 2cm / AFI < 5)
- NONstress test:
- –> reactive fetal HR monitoring : > 2 acceleration , baseline 110-160/ min, moderate variablility , normal fetal acid-base status
–> NONreactive NST:
< 2 acceleration : fetal hypoxemia + acidemia
- AF Voln: single fluid pocket > 2 * 1 cm / AFI > 5
- fetal movement: >3 general body movement
- fetal breathing movement: >1 breathing ep > 30 sec
Late deceleration
etio?
late term preg > 41 wks
–> chronic fetal hypoxemia : !!!!
interrupt intervillous BF —-> UTEROPLACENTAL INSUFFICENCY!!
—> CNS suppression + fetal demise
—-> peripheral tix blood supp, redistribute to BRAIN
- -> dec movement, RR, muscle tone !!!
- -> oligohydramnios
placenta abruption ?
- —> PLACENTA vasoconstriction + ISCHEMIA !!!
- -> endothelial dysfunction
—> Premature placenta separation from uterus!!
- -> 3rd trimester !!
- -> PAINFUL abd pain , BACK pain , uterine TENDERNESS
-> fetal FR deceleration !!!!! fetal hypoxia
- -> VAGINAL BLEEDING!!!! ( mini bleeding if w/in intrauterine cavity)
- –> DISTENDED uterus
—> HIGH frequency CONTRACTIONS !!
RF: HTN, cocaine, smoking
- > prior abruptio placentae
- > preeclampsia
- > abd trauma
dx: clx
- > U/S +/- retroplacental hematoma
comp:
- > fetal hypoxia, preterm birth , mortality
- > mat hemorrhage, DIC !!!!
uterine rupture
?
-> during LABOR !!
RF:
-> PRIOR c/s delivery
- > SUDDEN vaginal bleeding !!!!
- —>SEPARATION of INELASTIC UTERINE SCAR TIX!!!
- > intense abd PAIN !!!!
- —-> palpable fetal parts thru abdominal wall ( IRREGULAR MASS)
-> FHR abnormal : deceleration , bradycardia!!!!
———-> IRREGULAR contraction + DECREASE in intensity !!
- -> LOSS fetal STATION!!!
eg. +1 –> -3
CONTRA: OXYTOCIN: induce labor augmentation + induction !
Oligohydramnios
AFI < 5 cm
early gestation?
late ?
- early: fetal etio
FGR : 1st trimester SYMMETRIC
- -> aneuploidy (DS trisomy 21)
- > renal agenesis : ACEI / ARB , POTTER syn, pul hypoplasia
-> Post urethral valves : bil HYDRONEPHROSIS
–> AF DEP on normal fetal urine production
- 2nd/ 3rd trimester:
Fetal growth restriction !!!
ASYMMETRIC :
—»» “ HEAD -sparing “ growth lag
!!!!!! –> uteroplacental insuff ( FGR) : HTN / preGDM / cocaine / drugs use
dx: MAT VASCULAR DX —> UMBILICAL ARTERY DOPPLER U/S !!!
- -> maternal : dehydration
- > SPONTANEOUS ROM ( normal fetal growth) @ TERM!!!!
sym: inc CLEAR vaginal discharge
- -> sudden/ slow leakage
rx; URGENT delivery
hyperemesis gravidarum
lab?
also occur with:
wernicke encephalopathy!
-> vomiting: loss HCl
–> met alkalosis
inc PH , inc HCO3
–> compensate PaCO2 inc
-> hypoglycemia
-> elev AST, ALT
** normal preg: hypocapnia : direct + of progesterone on CNS : inc Resp drive –> hyperventilation + chronic resp alkalosis ( PCO2 dec )
esophageal perforation
sym?
dx?
rx?
- > boerhaave syn
- > esophagitis
- > endoscopy , trauma
sym:
- > Chest / back , epi pain
- > Crepitus , HAMMAN sign ( crunching sound )
- > Pleural effusion with atypical fluid
dx:
- > CXR/ CT : widened mediastinus , pnmediastinus, pnthroax, pleural effusion
- > Ct : esophageal wall thickening, mediastinal fluid collection
- > esophagography with water soluble contrast : leak from perforation
rx: NPO, IV ab, PPI
- > ER sx repair !
cervical conization
COLPOSCOPY
(GS) dx CIN !!!!
ind?
comp?
PAP smear –> high risk COLPOSCOPY
—-> ENDOCERVICAL CURETTAGE
- > CIN 2 + 3 ( high risk progress into SCC)
- –> MARGIN free: repeat PAP + HPV co-testing Q1y , Q2y
tech: COLD knife CERVICAL CONIZATION / electrocautery ( LEEP)
comp: -> cervical stenosis : scar tix !!! -> preterm birth -> preterm PROM -> 2nd trimester preg loss
*** DOES NOT WEAKEN the PELVIC FLOOR MUSCLE !!!
** not limit mobility : not related to thromboembolism
asherman syn?
endometrial affected: intrauterine adhesion from inf / sx:
- > D&C
- > endometrial ablation
- > endometrial resection
lab: NO progesterone on w/drawal challenge
- > NORMAL ESTROGEN, FSH !!!
placenta accreta
risk?
sym?
rc?
-> morbidly adherent placental attachment to MYOMETRIUM!!
RF:
Placenta previa + prior uterine surgery
–> C/S , D&C , myomectomy
—> MANUAL PLACENTAL EXTRACTION!!
sym:
- > prenatal: U/S : low lying placental inc # lacunae , myometrial thinning
- —> Uterine enlargement + atony !!
-> postpartum: adherent placenta, postpartum hemorrhage !!!!
primary vs 2ndry dysmenorrhea?
- primary:
physio + pain with MC ( asso sym)
—> excessive Prostaglandin production !!!!
uterine contraction + promotes endometrial sloughing
- -> usually painful MC in aldoscents after ovulatory , regular MC established already
- -> midline pain radiate to BILATERAL legs / BACK !!!!
- –> clx dx
- -> not req PE
rx: NSAIDS : inhibits prostaglandin synthesis
- Secondary: PATHOLOGIC
- -> UNILATERAL nonmidline pelvic pain !!! ( LOC of PAIN)
perineal laceration s/p vag delivery
rx?
1st degree:
-> vaginal mucosa + perineal skin
2nd : bulbovavernosus muscle + perineal body
–> high vascularity
vag tix
3rd: ext anal sphincter + int anal sphincter
- –> pudendal nerve injury
4th: rectal mucosa
- –> ANAL / fecal incontinence !!!
Uncomplicated: no fever / purulence
–> conserve rx: NSAIDS , sitz baths
ASX bacteriuria
sym?
etio?
rx?
> 100,000 CFU/ ml Bacteria
- –> Leuukocyte esterase + !!!!
- > nitrates Variable
–> NO sym: dysuria, urinary freq
- –> Progesterone: SM relaxation + uretheral dilation: inc risk acute pyelonephritis !!!
- > FLANK pain, FEVER, tachycardia maternal + fetus !
risk: Sepsis, ARDS, preterm labor
dx: u/c screening initial visit
- -> repeat U/C ( test of cure ) performed few wks after completion of Ab therapy
RF:
- > preGDM
- > hx UTI
- > multiparity
etio:
- > e.coli (MC)
- > klebsiella
- > enterobacter
- > GBS : intraamniotic inf
rx: 5-14 days to complete el bact!!
u/c sensitivity testing:
- > cephalexin !!
- > amx- clauvlanate
- > nitrofurantoin
- > fosfomycin
ruptured ovarian cyst
sym?
dx?
rx?
acute pelvic pain at repro age
- > peritoneal irritation leaking cyst content
- > unilateral lower abd pain after strenuous activity / sex
dx; CBC
u/s : pelvic FREE FLUID from cyst !!!!
rx:
- > stable : NSAIDS
- > unsable: SX
weight gain in preg?
kcal 350-450 / day
12-11-7-5 ( +5/6kg)
BMI < 18.5 : ideal gain 12-18 kg
18.5- 24.9 : gain 11-16 kg
25-30 : gain 7-11 kg
> 30 : 5-9kg
comp underweight:
- -> LBW
- > preterm delivery
- > Fetal GROWTH RESTRICTION!!
- —> inc risk Neonatal POLYCYTHEMIA/ HYPERVISCOSITY!!!
excess WG:
- > GDM
- > fetal macrosomia
- > C/S
sickle cell dx in preg
sym?
rx?
risk?
-> inc met demand
-> hypercoag state !!
-> vaso-occlusive pain crisis
-> acute pain episodes hrs- days
@ chest, abdomen, long bones
MICROVASCULAR OCCLUSION , dec perfusion , tix ischemia ( abdominal tenderness)
rx: flid + opioid
risk:
- > inc risk preeclampsia
- > placental abruption
- > fgr
- > preterm delivery
uterine inversion
sym?
comp?
rx?
- > postpartum hemorrhage
- > excessive TRACTION UC + abnormal adherent placenta !!!!
-> severe abd pain + “SMOOTH” MASS PROTRUDING from cervix / vag
comp
- -> hemorrhagic shock , hypotension, neurogenic shock
- -> paradoxical bradycardia
rx: manual replacement of uterus !!!!
- -> req uterus to relax!!
* ** uterine relaxant: terbutaline, NG :reserved for unsuccessful pt
- -> se/ uterine atony
*** oxytoxin ( uterotonics) are DISCONTINUED!!!!
spontaneous abortion
rx?
- > heavy vag bleeding, cramping , DILATED CERVIX
- > NO POC yet!
u/s: intrauterine gestional lower uterine segment : inevitable abortion!!!
rx: SUCTION CURETTAGE : UNstable pt
-> tachycardia, hypotensive , anemia
Roh(D) IG
- -> stable pt: expectant / MIFEPRISTONE ( synthetic prostaglandin antagonist) / MISOPROSTOL ( PGE-1 agonist) : uterine contraction + expulsion retained POC
- –> SLOW ONSET!
HIV rx?
Antepartum:
- > HIV RNA viral load at initial visit, q2-4 wks after initial / change rx, monthly until undetectable , q3m
- > start RX asap -> avoid amniocentesis unless viral load <1000
intrapartum: avoid ROM, fetal scalp electrode, operative vag delivery
- > viral load <1000 : ART + vag delivery
- > viral load > 1000 : ART + ZVD + C/S
Postpartum:
- > mother: continue rx
- > infant ( mother viral load < 1000) : ZVD
- > infant (mat viral >1000) : multirx ART!!
idopathic ICH
sym?
dx?
rx?
RF: obese women
-> rx
sym:
- > HA
- > vision loass, enlarged blind spot
- > pulsatile tinnitus
- > diplopia , palsy N6
- > papilledem
dx: neuroimaging: MRI brain !!! BEFORE LP exclude other causes cerebral herniation !!!
MR venography r/o Cerebral vein thrombosis !!!!
—> Rx: heparin
-> LP : elev opening pressure
rx: WL
- > acetazolamide
Mg toxicity
?
HyperMg:
due to—> renal excretion: risk for RENAL FAILURE !!! inc Cr
mild:
- > n, flushing, HA, hyporeflexia
moderate:
-> areflexia, hypocalcemia!!!
somnolence
severe:
- > Resp failure, !!!! paralysis, cardiac arrest
- -> CONTRA in MG pt. !!
rx: stop MG
give : IV ca gluconate bolus!!
DRE
prior exam?
-> transabdominal U/S prior to confirm –> det route of delivery !
vulvodynia ?
-> vestibular hypersensitivity : persistent localized vulvar pain with light tough!!!
NONalcoholic fatty liver dx?
type 2 DM, obesity
-> eleve AST/ALT < 1 : steatohepatitis
—> insulin resistance
unregulated hepatic TG synthesis , peripheral lipolysis + free fatty acid uptake into liver
dx:
u/s
-> hyperechoic texture : hepatic steatosis !!!!
ASX
-> met syn
acute fatty liver pregnancy
sym?
rx?
- > 3rd trimester !!!
- > Mitochondira (LCHAD) enz deficiency: microvesicular fatty enz not functioning !!
!!!! -> fulminant liver failure : scleral icterus, profound HYPOGLYCEMIA ( cannot break down glc), inc bilirubin
- -> RUQ pain !
- -> AMMONIA
lab:
- > LFT: elev ast, alt (2-3x normal) !!!!
- > elev PT
- > elev TOTAL bilirubin
- > RUQ pain
- > thrombocytopenia PT < 100,000/mm !!!!
- -> inc risk MOF, DIC !!!!!
- -> pul edema ( inc hydrostatic pressure)
dx: liver biopsy
rx: IMMEDIATELY DELIVERY!!!
high mortility rate regardless gestation AGE
GBS
screening?
ppx?
ind?
rx?
antenatal sx: Rectovag culture 36-38wk
ind for intrapartum PPX:
- –> GBS bacteriuria / GBS UTI in current preg
- –> GBS + rectovaginal culture current preg
- –> unknown GBS + any one:
1. < 37 wk gest
2. intrapartum fever
3. ROM > 18 hrs - -> prior infant with early onset neonatal GBS inf
intapartum PPX: IV PCN
invasive cervical ca
sym?
sym:
- > irregular Vag bleeding + cervical mass !!!!
- > POSTCOITAL!!
- > no routine PAP test screening
*** HIV pt: Q6-12 mo screening !!
risk:
- > IMP
- > smoking!!!!!!!!!!
- > multiple sex partners
- > HPV 16. 18, 31, 33
PE:
- > cervical FRIABILITY ( bleeding with manipulation)
- > raised , EXOPHYTIC MASS!!!!
- > tix necrosis , watery , mucoid vag discharge
dx:
Cervical BIOPSY!!!!
safe during preg
rx: oncology + sx
Staphylococcal toxic shock syndrome
risk?
patho?
sym?
rx?
Risks:
- > Tampon use
- > Nasal packing
- > Sx /postpartum wound inf
Patho:
1. S. aureus
Exotoxin —> superantigens TSS-1
Sym: -> Fever >38.9 C -> Hypotension -> Diffuse macular rash involving palms & soles Desquamation 1-3 wk after disease onet -> v/ d AMS w/o focal neuro signs
rx:
fluid replacement
-> Removal of foreign body (eg, tampon)
-> !!!!! Antibiotic therapy (eg, clindamycin plus vancomycin)
ceftriaxone?
rx
Macrolides
rx?
Ceftriaxone, a third-generation cephalosporin
—> rx: gram-negative infections (eg, Neisseria meningitidis)
macrolide : rx: chlamydia trachomatis
Granulosa cell tumor
patho:
Sex cord–stromal tumor
↑ Estradiol !!!!!
↑ Inhibin
sym:
Complex ovarian mass : elev estradiol !!! uncontrolled endometrial proliferation !!!
—> inc risk endometrial hyperplasia/ ca
-> Juvenile subtype
Precocious puberty
-> Adult subtype
Breast tenderness
Abnormal uterine bleeding
-> Postmenopausal bleeding
hx:
Call-Exner bodies (cells in rosette pattern)
rx:
Endometrial biopsy (endometrial cancer)
Surgery (tumor staging)
-> cmt/ radiation
Granulosa cell tumor
patho:
Sex cord–stromal tumor
↑ Estradiol !!!!!
↑ Inhibin ( suppress pituitary FSH release via negative feedback)
sym:
Complex ovarian mass : elev estradiol !!!
uncontrolled endometrial proliferation !!! THicken > 4 mm endometrial stripe on u/s
—> inc risk endometrial hyperplasia/ ca
-> Juvenile subtype
Precocious puberty
-> Adult subtype
Breast tenderness!!! : fibrocystic change
!!!-> Abnormal uterine bleeding
!!!-> Postmenopausal bleeding
hx:
Call-Exner bodies (cells in rosette pattern)
rx:
Endometrial biopsy (endometrial cancer)
Surgery (tumor staging)
-> cmt/ radiation
preterm labor
unstable?
vs
stable
GA < 32
GA 32-34
GA > 34
rx?
dx?
Maternal instability , IU inf, fetal distress/ demise : IMMEDIATELY delivery!!!
Stable:
!!!! 1. < 32 wks : very preterm
-> antenatal steroids
-> IM PENICILLIN if GBS +/ unknown
-> tocolysis: INDOMETHACIN (NSAIDS: CO1 +2 inhibitor) : dec PROSTAGLANDIN production : fetal vasoconstriction –> dec renal perfusion
+ fetal oliguria
-> MgSO4: neuro protection !!
- 32-34 wks (moderate preterm)
- > antenatal steroids
-> PNC if GBS/ unknown
-> tocolysis :
indomethacin (se/ oligohydramnios, closure PDA)
NIFIDIPINE ( se/ mat hypotension / tachycardia)
- 34-37 wks: late
- > antenatal steroids
- > if GBS/ unknown
dx: FETAL FIBRONECTIN TESTING : GA 22-35 -> det preterm labor
*** IM 17- hydroxyprogesterone : PRIOR preterm delivery !!! to prevent recurrence
secondary late postpartum hemorrhage
etio? inc risk: -> prolonged labor -> macrosomia -> intraamniotic inf
- retained Product of conception ( POC)
- -> LATE HEAVY bleeding : sat > 1 pad/ hr , passage LARGE CLOTS!!!! +/- uterine ATONY!! / FIRM UTERUS!!
rx: D& C - Placenta site subincolution :
- > heavy bleeding
- > uterine atony
rx: uterotonics ( oxytocin, methlergnovine, carboprost) - postpartum endometritis
- > fever
- > uterine tenderness
- > purulent lochia
rx: IV ab ( clindamycin + gentamicin)
Epidural analgesia toxicity ?
- > Bupivacaine : local anesthetic slow release
sym: initially blocks inhibitory Na+ neural pathways : cause CNS OVERACTIVITY: peri-oral numbness, metallic taste, tinnitus, GTC seizure, CV collapse
rx: cessation rx, BZD
Uterine procidentia ( full uterine prolapse)
pelvic organ prolapse
definition?
sym?
rx?
RF:
- > obesity
- > multiparity!!!!!!
- > hysterectomy
- > postmenopausal age
sym:
-> pelvic pressure: bulging mass INC with VALSALVA maneuver !!!!! : splinting : apply pressure to help imp bowel movement
—-> multiparity: inc intraabdominal pressure + pelvic floor wkening + laxity! STRESS UI
———-> levator ani muscle complex injury !!!! ( ext anal sphincter)
- > ob voiding
- > urinary retention
- > urinary incontinence
-> incomplete defecation + constipation: posterior prolapse!!!
- > fecal urgency, incontinence
- > sexual dysfunction
rx: ASX: OBSERVE -> WL -> kegal exercise -> vaginal pessary !!!! -> surgical repair : poor candidate : eldery , obese, class III HF , poor control DM
Mullerian agenesis ( mayer- Rokitansky -Kuster- Jauser syn)
sym?
- > ABSENT Uterus + Cervix + upper 1/3 VAGINA !!!
- > NORMAL 2ndry sexual char ( breast, ext genitalia) + OVARIES!!!
lab:
- > normal FSH ( normal ovarian function) !!!!
- > normal ext genitalia + lower 2/3 vagina ( BLIND vaginal pouch) !!!
rx: renal u/s
- -> screen for duplicated ureters
menarche age?
thelarche age?
pubarche?
menarche 12.5 yr
Primary amenorrhea:
–> if >13 yr no menarche + NO 2ndry sex char
or
–> > 13 yr no menorche WITH 2nd sex char
IUD
contra ind?
-> explained , abnormal vaginal BLEEDING!!!!
etio:
- > inf ( PID, cervicitis): actinomyces isrealii ( anaerobic bat)
- -> filamentous, G+ bacilli , branching pattern
rx: PNC - > polys
- > endometrial Ca/ hyperplasia : obesity
dx: NEED further dx !!!!
contra:
- > ACTIVE breast Ca ( not contra with FX)
- > active liver dx
- > pregnancy
T sign?
Lambda sign?
T sign:
- -> MONOchorionic diamniotic twin
- –> inc risk : TTTS
- > unbalance AV anastomoses : shared placenta vessels
- –> donar twin: low resistance/pressure : anemia, RF, oligohydramnios , HF , FGR
- –> recipient twin: polycythemia, polyhydramnios, cardiomegaly, high output HF, hydrops fetalis
lambda sign:
–> Dichorionic Diamniotic twin
Septic pelvic thrombophlebitis
sym?
DAY 5-6 s/p postpartum: postpartum fever due to injury
- > hypercoagulable state thrombus, and hematogenous spread of infection to the pelvic veins (eg, ovarian veins)
rx: heparin IV
surgical site infection
-> cellulitis
sym?
rx?
incisional bact contamination
- > wound induration + erythema
- > spread to surrounding subcutaneous tix
- > edema, subcutaneous fluid accumulation , inc peri-incisional pain
rx:
cephalexin
dysgerminoma
lab?
inc LACTATE DEHYDROGENASE
- > malignant GERM cell tumor
- > rapid enlarging , painful masses
CRL ?
best assessment GA : first trimester
–> gestational sac diameter: 4.5-6 Gestational wk +/- 5-7 days
CRL
–> btwn wk 7-14 !!!
+/- 3-5 days
biparietal D, HC, femur length:
14-20 wk
21-30 wk
>30 wk
Urethral injury?
vagina
- > urinary retention , dribbling
- > urinary freq, dysuria
-> slow / interrupted stream from foreign body
postpartum Urinary retention
RF?
sym?
rx?
-> inability to void > 6 hrs s/p vag delivery !!!
- > acute urinary retention : overflow incontinence
- > over distended bladder
etio:
- > perineal trauma : prolong 2nd stage labor / perineal laceration : PUDENDAL N injury
- > reduce sensory / motor sacral SC impulses from regional neuraxial anesthesia ( epidural anesthesia) : BLADDER ATONY!!!
- > operative forceps assist vag delivery
rx: !!!! int urethral catheterization + reassurance , self limiting resolves < 1 wk
Euthyroid sick syndrome?
alternation biochem thyroid function test: NONTHYROID ILLNESS !!!!
- > LOW total T3 + free T3
- > NORMAL T4 + TSH
thyroid function in pregnancy
lab?
Estrogen + syn TBG —-> dec TBG clearance
—> inc TH production to maintain free hormones level
-> hcg directly + TSH receptors : inc TOTAL T4 + T3—> inc/ normal free T4
- –> feedback shutdown TSH!!!
- –> TSH DECREASE!!!
brenner tumor
sym?
benign subtype epithelial ovarian tumor
—> like bladder
-> pale, yellow tan , encapsulated
“coffee bean nuclei”
-> ASX
embryonal ca?
- > ovarian germ cell tumor
- > YOUNG Women
–> abd ascites, pelvic mass, preg sym ( breast tenderness)
- > aFP + HCG elev!!!
- > false + pregnancy test
late + post -term pregnancy
def?
RF?
comp?
rx?
late term: > 41 wk GA
Post -term : > 42 wk GA
RF: prior post term preg
- > nulliparity
- > obesity
- > fetal anomalies ( anencephaly)
comp:
fetal:
- > macrosomia
- > dysmaturity syn
- > oligohydramnios <2 cm deepest pocket !!!!
- > demise
Maternal:
- > severe ob laceration
- > c/s delivery
- > postpartum hemorrhage
rx: freq fetal monitoring ( nonstress test)
- > DELIVERY prior to 43 wk
Rheumatic heart dx?
MC: MS > AR
-> new atrial fibrillation can further increase transmitral gradient and left atrial pressure,
with dramatic worsening of pulmonary congestion and pulmonary edema.
migraines during pregnancy.
rx?
1st line: APAP + Beta blockers / CCB
2nd /3rd:
opioids (eg, acetaminophen-codeine), antiemetics, and NSAIDS (in the 2nd trimester only)
*** ergotamine/ Triptans : contra in preg: risk HYPERTONIC uterine contraction + vasoconstriction : preterm labor, FGR ( triptans)
** TOPIRAMATE : contra in pregnancy: fetal cleft lips/ LBW
** NSAIDS: avoided in 1st + 3rd trimester: spontaneous abortion, premature PAD closure, oligohydramnios, renal dysfunction
Ovarian hyperstimulation syndrome
OHSS
sym?
patho:
inc HCG enhances ovarian vascular permeability
—> 1-2 wks
–> exaggerate ovarian response: BIL enlarge, cystic ovaries , multiple follicles
dx: US : inc doppler flow
- > over-expression VEGF!!!
- > acute fluid shift to EVS : vascular permeability + capillary leakage
- > 3rd spacing , ascites, abd distension
- -> pleural effusion , IV dep
- > severe thromboembolism , RF, death
TOA?
–> HIGH FEVER , cervicitis
comp PID –> UNILATERAL lower abd pelvic pain, ovarian mass
–> FItz- Hugh Curtis syn: vomiting + RUQ pain !!!
- > u/s : MULTICYSTIC complex adrenal mass with enhancing rims
rx: IN- patient rx: IV cefoxitin ( G - bact )+ oral doxycycline ( G+ bact) !!!
postmeno bleeding
dx?
—> > 45 women with ENDOMETRIAL CELL in PAP test: need to perform : ENDOmetrial Biopsy!!!
TV U/S endometrium
or
> 4 mm: endometrial biposy
—> atypia neoplasia : Progestin, SUGERY!!
endometrium < 4 mm : no additional dx
–> rx / progestin IUD
Intrahepatic cholestasis of pregnancy
sym?
lab?
risk?
dev @ 3rd trimester: inc ESTROGEN induced
sym: -> Generalized pruritus worse on hands & feet @ night !!!!!!!! -> No associated rash -> RUQ pain
lab:
!!!! ↑ Total bile acids (≥10 µmol/L) —> cross placenta !!!
↑ Liver transaminases (typically <2x normal, rarely >1000 U/L)
± ↑ Total & direct bilirubin
comp:
- —> IU fetal demise: BILE ACIDS > 100 umol/L
- > preterm delivery
- > meconium stain AF ( Bile acid elev)
- > neonatal RDS
rx: ursodeoxycholic acid ( dec BA level)
- > anti-histamines
- > delivery @ 37 wks GA
Routine Postpartum screening ?
intimate partner violence
s/p 3-6 wks delivery
SERM
tamoxifen
Raloxifene ?
competitive inhibitor estrogen receptor binding
—> ANTAGONIST effect breast!!
se:
- > hot flashes
- > venous thromboembolism : DVT, Pul emboli, retinal vein thrombosis !!!!!
!!!!!! -> endometrial hyperplasia + Ca ( tamoxifen only)
-> uterine sarcoma ( tamoxifen only) !!!!!! —> estrogen agonist on UTERUS
protective:
- > CVD
- > inc bone density ( Roloxifene)
pubic symphysis diastasis ( physio widening ) ?
—> inc progesterone + relaxin : inc PELVIC mobility + promote physio widening ( diastasis ) of the pubic symphysis to faciliate vag delivery !!!!
etio: traumatic delivery
-> fetal macrosomia
-> forceps assised vag delivery
multiparity
sym:
- > suprapubic pain radiates to back, hip, thigh, leg
- > exacerbated by walking !!!
- > pt tenderness to palpation over pubic symphysis + waddling gait
rx:
-> PT
-> pelvic support
recovery in 4 wks
femoral nerve damage ?
- > McRobert maneuver
- > numbness over ANT + medial thigh
- > inability to extend leg, flex hip, diminished patellar reflexes
GDM
screening?
target?
rx?
-> screening 24-28 wks GA!!!
inc risk of:
- > HTN, preeclampsia
- > fetal macrosomia
- > C/s
lab:
fasting glc < 95mg/dl
OGTT 1hr< 140 mg/dl
2 hr < 120mg/dl
any ONE above need RX + dx with GDM!!
—> INSULIN: does NOT cross placenta
!!! F/U post partum : fasting glc 24-72 hr
-> 2 hr 75g GTT at 6-12 week visit !!
- ** gliflozin : SGLT-2 inhibitor : dec blood glc , inc glc excretion in urine
- > se/ UTI, WL
- ** TZD ( pioglitazone) : : imp insulin sensitivity + PPAR receptor
- -> se/ edema, fluid retention, HF
shoulder dystonia
rx?
BE CALM
Breath , do not push
Elev leg, flex thigh, hip –> McRoberts
Call for help
Apply suprapubic pressure
enLarge vag opening with episiotomy
Maneuvers
septic abortion
RF?
sym?
rx?
RF: retained POC from
- > elective abortion with nonsterile technique
- > missed / incomplete abortion
sym:
- > fever, chills, abd pain
- > sanguinopurulent, MALODOROUS vag discharge
- > boddy, tender uterus , dilated cervix
dx: pelvic u/s : RETAINED POC , thick endo stripe
rx: IV fluid , AB
- > ER: SUCTION CURETTAAGE !!!
complete abortion?
- > VAG bleeding
- > cervix OPEN
- > ALL POC
PE:
-> empty uterus
normal adenxa
-> closed cervix
Grave’s dx in pregnancy?
–> neonatal thyrotoxicosis
- > Transplacental passage mat Anti-TSH receptor ab
- > ab bind to infant TSH receptor + excessive TH release
sym: warm, moist, tachycardia
- > poor feeding, irritability, poor WG
- > LBG / PRETERM birth
dx: mat anti-TSH receptor AB > 500 % normal !!!!!
rx: self resolve w/in 3 mo !!
- > methimazoe + beta blocker
Nonviable fetus :
Anencephaly
rx?
Fetal dx:
Acardia
Anencephaly : NTD defect @ wk 5-6 GA
Bil renal agenesis
Holoprosencephaly: absent cerebrum , calcarial defect, abnormal cerebellum / BS
Intrauterine fetal demise
Pul hypoplasia
Thanatophoric dwarfism
Rx:
spontaneous Vaginal delivery
No fetal monitoring
Neonatal rx:
Palliative care if not stillborn
NTD PPX: 0.4 mg folic acid daily
-> high risk : 4mg/ daily
CTS in pregnancy
rx?
rx:
- > WRIST SPLINTING
- > steroids injection
- > sx severe / refractory sym
–> resoloves spontaneously after childbirth
Achondroplasia
non-lethal AD:
- > bone dysplasia -> macrocephaly, frontal bossing,
- > midface hypoplasia,
- > genu varum, and limb shortening.
type 2 OI
u/s dx?
Patho:
AD
Type 1 collagen defect
u/s:
Multiple fractures
Short femur
Hypoplastic thoracic cavity: pulmonary hypoplasia
Fetal growth restriction
Intrauterine demise
Prognosis:
Lethal
PCOS
sym?
comorb?
lab?
rx?
sym: SLOW progressive onset!!
- > Androgen excess (eg, acne, male pattern baldness, hirsutism)
- > Oligoovulation or anovulation (eg, menstrual irregularities)
- > Obesity
- > Bil enlarged Polycystic ovaries on u/s
patho: ↑ Testosterone levels ↑ Estrogen levels LH/FSH imbalance --> will have w/drawal bleeding!!
Comorbidities -> Metabolic syndrome: eg, diabetes: NIGRICANS: insulin resistance, HTN -> OSA -> Nonalcoholic steatohepatitis -> Endometrial hyperplasia/cancer
Rx: Weight loss (first-line) OCP : mc regularity !!! Letrozole: aromatase inhibitor --> inhibit neg feedback : normalize LH, FSH for ovulation induction
candida intertrigo?
topical nystatin : clotrimazole
sym: vulvar pruritis
- -> erythematous plaques with SATELLITE lesions inc inguinal folds
-> poor control DM
rx to AVOID in MG?
- -> NMJ : autoab against ach receptor skeletal muscle
- –> avoid resp muscle wkness!!!
Magnesium sulfate: inhibit ach release at NMJ : trigger myasthenic crisis!!! )
Fluoroquinolones, aminoglycosides Neuromuscular blocking agents CNS depressants Muscle relaxants Calcium channel blockers Beta blockers Opioids Statins
TG ind pancreatitis
lab?
rx?
dx: LIPID panal !!!
TG level > 1000 !!!
—> inc AMYLASE + LIPASE
rx: IV fluid, pain control
- > glc> 500mg/dL : insulin infusion
-> glc < 500 mg/dL / severe pancreatitis : Lactic Acidosis, hypoCa, : apheresis : therapeutic plasma exchange
Premenstrual syndrome and
premenstrual dysphoric disorder
sym?
dx?
rx?
sym:
- > occur during luteal phase 1-2 wk prior to MC!!!!
sym: bloating, fatigue, headaches, hot flashes, breast tenderness
Affective sym: anxiety, irritability, mood swings, decreased interest; more severe in premenstrual dysphoric disorder
dx:
Symptom/menstrual diary
rx:
SSRI
HSV prior
rx?
hx genital HSV : receive prophylactic antiviral therapy from wk 36 GA till delivery
—> reduce active lesions at delivery + C/S if currently @ active stage !!
Mix Urinary incontience
dx?
rx?
dx:
VOIDING diary!!
–> to det optimal rx
rx: bladder training + lifestyle changes
- > WL, smoking cessation , dec Etho,
- > kegals
- *** urodynamic tesing: measure bladder filling + empty ( cystometry) , urine flow, pressure ( urethral , leak point)
- —> reserve for complicated UI ( no response to rx) / considering sx intervention
Klumpke palsy?
C8-T1: ipsilateral miosis + ptosis ( Horner syn)
-> "Claw hand" Extended wrist -> Hyperextended MCP joints -> Flexed IP joints -> Absent grasp reflex!!! !!! -> Horner syndrome (ptosis, miosis)
-> Intact Moro & biceps reflexes
rx: gental massage + PT
-> recovery in few months
if 3-6 mon ths not improve: SX
Erb- Duchenne palsy:
MC brachial plexus injury: C5-6th
–> ↓ Moro & biceps reflexes on affected side
—> “Waiter’s tip”
->Extended elbow
-> Pronated forearm
Flexed wrist & fingers
—> Intact grasp reflex!!!
Breast abscess
RF?
sym?
dx?
rx?
Lactational mastitis :
RF:
maternal age> 30
-> nulliparity
-> smoking
sym:
- > fever , malaise
- > focal inflammation: UNILATERAL breast erythema + pain
- > fluctuant , tender mass
dx:
If NO improvement after AB with systemic sym: breast u/s
rx: Ab: dicloxacillin / cephalexin ( bother effective against MSSA)
- > drainage with u/s guide / sx incision
oxytocin toxicity?
excess / proling oxytocin:
- —> effect as ADH ( vasopressin)
- -> elev level renal CT : inc water reabsoption!!
se/ acute hypoNa
- > dec serum OSM
- > inc free water movement into brain cell : cerebral EDEMA + seizure!!
-> postpartum seizure in eclampsia
lab: LOW Na !!!
- > severe hypoNa
rx: cessation rx
- > HYPERTONIC saline ( 3% saline) raise serum osm + reverse cerebral edema!!
** ICH : BP > 160/ 110
pseudocyesis ?
-> sym early prenanacy + believe she is pregnant!
somatization of stress : affects HPO axis
- -> early preg sym
- > weight gain , amenorrhea
rx: psy rx
interstitial cystitis ( bladder pain syn)
sym?
dx?
tx?
-> asso with psy + pain dx ( fibromyalgia)
sym:
- > bladder pain with filling , RELIEF with voiding
- > inc URINARY freq , urgency
- > dyspareunia
dx: bladder pain with NO other cause for > 6 wks
- > normal U/A
rx: not curative
- > beh mod: bladder training , IV fluid
- > amitriptyline, pentosan polysulfate Na
- > analgesics acute exacerbation
urethral diverticulum?
abnormal outpouching of the urethra, can cause urethral tenderness, urinary frequency, and dyspareunia.
!!!! –> tender anterior vaginal mass
- > purulent urethral discharge
- > inc pain with voiding
Beckwith-Wiedemann syndrome
- > polyhydramnios;
- > macrosomia
- > omphalocele
Cystic fibrosis
-> hyperechogenic bowel or absent gallbladder on prenatal ultrasound
latent TB
rx?
+ IFN-g
TST : false + : pt with BCG vaccine
if positive: CXR f/u
SAFE with shielding
acute viral hepatitis ?
- fever, vomiting, and RUQ pain
- > travel to endemic regions.
- > jaundice and changes in stool color
ER OCP?
Ulipristal pill: progestin receptor blocker : delay ovulation + impairing implantation
can take up to 120 hrs s/p sex
-> alternate: copper IUD, oral levoorgesteral ( plan B)
*** progestin releasing subdermal implant : LONG acting , reversible !!!!
transdermal E -P patch: slow release!!!!
hidradenitis suppurativa?
chronic inflammatory
-> recurrent occlusion of hair follicles in intertriginous regions (eg, groin, axilla).
–> solitary, painful nodule surrounding a follicle up to month –> draining abscess sinus tract + scar formation!!
-> chronic, prog course + recurrences affect same region
-> 20-40 yr
RF -> Obesity, tobacco use, and family history.
Genital tract trauma (eg, vaginal laceration)?
- -> Operative vaginal delivery
- > infant > 4000g
- > nulliparity
- > prolong 2nd stage labor
—-> profuse postpartum hemorrhage
–> VAGINAL SIDEWALL DEFECT!!!
mini bleeding from cervical Os
- > Laceration of cervix or vagina
- -> supply from UTERINE artery!!
rx:
Laceration repair
VAGINAL hematoma
-> Enlarging vaginal hematoma
- —> MASSIVE OCCULT bleeding + hypovolemia SHOCK !!! Vag MASS protruding
- > mini vag bleeding
rx:
- > Nonexpanding: observation!!!
-> Expanding: embolization, surgery
bartholin duct cyst?
-> blockage bartholin gland duct
–> loc @ bil posterior vag INTROITUS : ducts that drain into vulvar vestibule 4 / 8 o’clock position
–> NOT palpable unless ductal blockage occurs : mucoid fluid buildup + cyst formation
sym:
ASX
-> blockage: vag pressure + discomfort with sex, walking, sitting
-> soft , mobile, nontender CYCTIC MASS behind POSTERIOR labium MAJUS!
rx: ASX: expectantly: observe !!
sym: incision _ drainage : word catheter placement
Epidermal inclusion cysts?
raised, mobile, flesh-colored nodules
-> associated with a central punctum.
Peripartum cardiomyopathy
?
—> LAST month of pregnancy / w/in 5 mo post-delivery!!
- > dyspnea and peripheral edema
- > acute pulmonary edema ( diffuse infiltrates )
- > hyperventilation and respiratory alkalosis.
–> inc JVP
Pul embolism ?
acute hyperventiliation + resp alkalosis
-> hypoxemia
vag sq cell ca?
–> vaginal bleeding, malodorous discharge, and an irregular ULCERATIVE lesion.
RF:
- > age >60,
- > chronic tobacco use
- > human papillomavirus infection.
dx:
- > biopsy
- —> determines the depth of invasion of atypical cells.
Normal labor progression?
contractions + cervical dilation
—> spontaneous ROM;
—> NOT cause acute onset of pain + minimal variability.
mittelschmer?
occur day 10-14!!
counting from first day of MC
–> rupture of follicule releases the egg.
- > physio corpus luteum cyst
- > lower pelvis pain at site of ovulation, ulilateral, last few days
- > resolve without rx
Copper IUD
—-> NOT rx for dysmenorrhea : inflammatory rxn in uterus + inc BLEEDING !!!!
Benefits:
- –> NO effect on HTN!!
- > high efficacy > 99%
- > no future on fertility
skene gland cyst?
bilateral PARAURETHRAL GLANDS - ant vag vestibular
–> urethral meatus
Gartner duct cyst?
incomplete regression of the Wolffian duct during fetal development.
–> lateral aspects of the upper anterior vagina.
bipolar dx in preg
rx?
LAMOTRIGINE
—> 2nd gen antipsy:
Quetiapine, risperidone can be considered
AVOID:
–> lithium : EBSTEIN anomaly!!! avoid in preg! lichen
–> valproate / carbamazepine : NTD , anencephaly , myelomeningocele
conflict of interest ?
inform consent influenced / biased by providers self INTEREST!!!
veracity ?
being truthful
eg. not informing alternative options if available
Pelvic congestion syndrome?
–> dull, ill-defined pelvic ache that worsens with intercourse or during long periods of standing.
renal venous thrombosis ?
subsequent unilat renal infarction
–> hypercoagulable state (eg, malignancy).
—> HEMATURIA!!
complete molar pregnancy (hydatidiform mole)
sym?
- -> abnormal proliferation of hyperplastic chorionic villi
- -> 46 XX, no fetus parts
–> abnormally enlarged uterus (ie, uterine size > gestational age)
Androgen insensitivity syndrome
sym?
- -> X-linked mutation in androgen receptor
- -> non functioning androgen receptors : peripheral androgen resistance !!
- —-> produce TESTOSTERONE!!!!
sym:
–> (46,XY karyotype)
- Non-functioning androgen receptor: prevent male reproductive st ( Wolffian duct, urogenital sinus ) : male external genitalia ( penis, prostate)
- –> female ext genitalia : shortened lower 2/3 vagina
Puberty: Testo –> aromatized into estrogen :
–> Breast dev + tall
—> PRIMARY AMENORRHEA : absent menarche by >15 yr with 2ndy sex char)
-> Peripheral androgen resistance: ABSENT or minimal axillary & pubic hair
- > Regression of MULLERIAN st ( internal st) : Absent uterus, cervix, & upper one-third of vagina
- —–>!!!!! Cryptorchid testes ( NO OVARIES)!!!
rx:
Gender identity/assignment counseling
-> Gonadectomy (malignancy prevention)
blunt abdominal trauma
induce abruptio placenta
rx?
- > hypovolemic shock from hemorrhage (ie, hemorrhagic shock)
- > hypotension, tachycardia, and cool extremities.
Rx:
- > rapid resuscitation with replacement of IV voln, transitioning from crystalloid to blood products
- > left lateral decubitus positon
MASSIVE transfusion protocol ( MTP): packed RBC : PT: FFP = 1: 1: 1 ratio to avoid coagulopathy from dilution of pt and clotting factors
** ER c/s : category 3 tracing : variability + late deceleration
*** CONTRA :: NE :
isolated hemo shock: perip vascular tone already INC ==> dec BV
–> dec Uterine BF : impair fetal O2
Acute cervicitis
sym?
rx?
FIRST trimester bleeding
-> closed cervix
- > ASX
- -> Mucopurulent discharge : yellow mucus, bloody at ext os
- -> NO vulvovaginal erythema
- > Postcoital/intermenstrual bleeding
- > Friable cervix !!!
dx: NAAT: chlamydia , neisseria
_. wet mount microscopy
-: > test of cure after RX
rx: emp rx: ceftriaxone + doxycycline
inc risk:
- > spontaneous abortion: rx/ mifefristone, misoprostol / surgical curettage
- > PPROM
- > neonate :conjunctivitis
retroperitoneal hematoma
Hemo shock !!!
no sign of uterine atony
- —> uterine artery injury
- -> rapid + massive blood loss acc in retroperitoneum
—> no incisional bleeding + mini abd / back pain
RX: HEMO UNSTABLE PT: ER LP!!
- ** CT scan abd + pelvis: STABLE pt
- -> arterial embolization control bleeding
Functional hypothalamic amenorrhea
sym?
- > relative caloric deficiency (eg, athletes, eating disorders)
- –> LOW BMI
lab:
- > decreased GnRH secretion in hypothalamus
- > NO withdrawal bleeding after a progesterone challenge due to low estrogen levels;
- > LH + FSH levels are LOW
- > low estrogen production
acute hemolytic transfusion reaction due to ABO incompatibility ?
lab?
comp?
rx?
- > Intravascular hemolysis
- > ABO incompatibility
- > within mins - hours of transfusion
- > fever !!!!
- > hemoglobinuria, acute RF: oliuria, anuria
- > hypotension + hemolysis !!!
lab:
- > Positive direct Coombs test!!!!!
- > Hemolysis (eg, ↑LDH, ↑indirect bilirubin)
Complications
- > Acute renal failure
- > DIC
rx:
- > IV normal saline + O2, vasopressors
transfusion rxn timeline ?
0-sec/ming: Anaphylactic : anti-IgA ab deirect against donar blood IgA
- –> angioedema , hypotension , resp distress/ wheezing, shock
rx: EPi
min - 1 hr: Acute hemolytic : ABO incompatibility ( often clerical error)
—> fever, flank pain, DIC, + Coombs test
1 hr - 6 hrs: febrile nonhemolytic (MCC) , TACO , TRALI, TTBI , urticarial
—-> cytokine acc during blood storage: fever + chills !!
> 2 days: delayed hemolytic
—> anamnestic ab response: Asx , hemolytic anemia , + coombs test , + new ab screen
Galactorrhea
sym?
lab?
- > PHYSIOLOGICAL galactorrhea is usually bilateral and guaiac (blood) negative
- –> milky, pale gray discharge
–> BENIGN
etio:
- > hyperprolactinemia, : pituitary prolactinoma,!!
- > Rx
- > hypothyroidism,
- > pregnancy,
- > Chest wall/nipple stimulation (eg, surgery, trauma).
lab:
-> serum prolactin and TSH levels
dx: MRI
rx: reassurance + f/u
Second stage arrest of labor?
—> NO fetal descent after pushing for:
≥3 hours if nulliparous
≥2 hours if multiparous
RF:
Maternal obesity
Excessive pregnancy WG
DM
Etio:
- > Cephalopelvic disproportion
- > Fetal Malposition !!! MCC
- —-> Ideal head position is: occiput Anterior
- > Inadequate contractions
- > Maternal exhaustion
Rx:
Operative vaginal delivery
C/s
Cell-free fetal DNA testing
noninvasive @ GA > 10
?
Maternal age ≥35 :
testing ind for?
- > fetal aneuploidy
- > Prior pregnancy with fetal aneuploidy
- > Parental-balanced robertsonian translocation
Applications
- > Screening for trisomy 21, 18, 13 & sex chromosome aneuploidies
- > Fetal sex determination
dx:
abnormal results : fetal karyotyping 1st trimester : Chorionic villus sampling / 2nd trimester amniocentesis
candida vulvovaginitis
sym?
normal vag flora
-> OCP : alternate vag flora balance
Vulvovaginal erythema and vaginal discharge : vulvar priritus , dysparenunia , dysuria
- > ph < 4. 5 !!
rx: oral azole
malignant hyperthermia?
genetic mut alters control IC Ca
-> trigger by volatile anesthetics , succinylcholine, excessive heat
sym:
- > Masseter muscle/generalized RIGIDITY!!
- > Sinus tachycardia
- > Hypercarbia resistant to increased minute ventilation
- > Rhabdomyolysis
- > Hyperkalemia
- > Hyperthermia (late manifestation)
rx:
- > Respiratory/ventilatory support
- > Immediate cessation of causative anesthetic
- > Dantrolene
inflammatory breast carcinoma
pain, erythema, and warmth.
- -> cutaneous edema + thickening Peau d’ orange
- > sup skin dimplinig , fine pitting
- > LAD
-> limit imp s/p AB // worsening infection ( breast abscess)
dx: mammography
u/s breast + axillary LN
-> tix biopsy : confirm dx
Infiltrating ductal carcinoma
or
lobular breast carcinoma
sym?
- > Skin dimpling or breast contour changes.
- > do NOT cause diffuse breast erythema, edema, and a peau d’orange appearance
IU fetal demise
rx?
< 24 GA : D& Evacuation / vaginal delivery
> 24 : vaginal abortion
–> can be delayed till pt is ready
congenital TOXOPLASMOSIS
sym?
rx?
Classic triad:
- > Chorioretinitis
- > Diffuse INTRAcranial calcifications @ BG !!!
- > Hydrocephalus!!!
- > Microcephaly (brain atrophy) or macrocephaly (severe hydrocephalus)
- > Seizures
- > jaundice, -> HSM, rash, FGR
dx: Toxoplama serology / PCR
rx: Pyrimethamine, sulfadiazine , folinic acid
VZV ?
FGR
-> limb abnormalities ( bone/ muscle hypoplasia )
Vulvar SCC ?
2ndry to persistent HPV
RF:
- > chronic tobacco
- > vulvar lichen sclerosus: malignant transformation !!!
- > ICP
- > prior cervical ca
- > vulvar / cervical intraepi ca
sym:
-> vulvar irritation, intermittent bleeding, and a UNIFOCAL, FRIABLE mass , white plaque @ labia majora
dx: vulvar
BIOPSY
Choriocarcinoma
RF?
sym?
rx?
—> gest trophoblastic Ca ( malignancy) : placental trophoblastic tix + secretes b-HCG
RF:
- > adv maternal age
- > Prior complete hydatidiform mole
sym:
- > Amenorrhea or abnormal vag bleeding
- > Pelvic pain/pressure
- > sym from MTS: (lung, vagina) —>pul MTS, dyspnea, chest pain , hemoptysis, dyspnea
- > enlarge uterine mass
lab:
elev β-hCG
-> CXR
rx: AGGRESSIVE ca !!! suction D& C !!!! Chemotherapy OCP s/p 1 yr
f/u serial serum b-HCG post evacuation !!
PID ind primary infertility
dx?
–> tubal scarring + ob
dx:
HYSTEROSALPINGOGRAM
-. mini invasive
identify uterine cavity anomalies ( bicornuate uterus)
CMV
sym?
–> vertical transmission
u/s:
- > PERIventricular Ca+
- > Intrahepatic Ca+
- > FGR
- > Hydrops fetalis
- > Ventriculomegaly
- > Microcephaly
dx:
–> amniocentesis
Neonatal sym:
- > Petechiae
- > HSM
- > Chorioretinitis
- > Microcephaly
Long-term seq:
- > Sensorineural hearing loss
- > Seizures
- > dev delay
congenital rubella ?
- > cong deafness
- > cong cataracts
- > cong Heart dx
–> large ant fontanelle !
GARDENERELLA vaginalis
bacterial vaginosis?
CLUE CELL
-> thin, gray white
FISH ODOR
Ph > 4.5
NO inflammation , vulvovaginal erythema
inc risk:
- -> PPROM / ROM < 37 GA
- > placental abruption
- > intraamniotic infection
epidural analgesia
se?
loc @ L2-L5 level, blocking nerves
se/
-> Hypotension (sym nerve fiber blocked
–> vasodilation (venous pooling), dec VR to the right side of the heart, and Dec CO
–> dec placental perfusion + fetal acidosis
rx:
- > IV hydration + vasopressor
- > left uterine displacement to imp VR
“high spinal” or “total spinal” injury?
- DANGEROUS
- > epidural ascends to SC depresses BS activity !!! T1-T4
Intrathecal injection / overdose anesthesia
sym:
hypotension, bradycardia , resp failure
- > diaphragmatic paralysis
- > cardiac arrest
C3-C5: dysphagia, resp paralysis
C6-8 : Upper ext wkness
“wet tap”
injury?
- > leakage CSF if dura is inadvertently punctured
- > postural HA , worsen with sitting up + imp with lying down after delivery
NTD
etio?
FR?
screening?
Types:
- > Anencephaly
- > Encephalocele
- > Spina bifida, myelomeningocele
RF:
- > Low folic acid intake
- > Methotrexate,
- > antiepileptics
- > Diabetes mellitus
- > Prior pregnancy with NTD
screening:
- > 2nd-trimester U/S: wk 15-20 GA!!!
-> Maternal serum AFP: > 2.5 MoM abnormal !!
Prevention
- > Average risk: 0.4 mg folic acid daily
- > High risk: 4 mg folic acid daily
elev etio:
- GA dating error (MCC)
- multiple gestation
Ovarian thecomas
?
- > benign sex cord–stromal tumors
- > MC in postmenopausal women.
- > secrete ESTROGEN!!
- > abnormal uterine/postmenopausal bleeding
- > NOT cause virilization.
Nonclassic congenital adrenal hyperplasia
patho?
sym?
rx?
AR: slow progression over yrs
lab:
- > ↓ 21-Hydroxylase activity
- > Normal glucocorticoids & mineralocorticoids
- > ↑ Androgens + elev DHEA !!!!
sym: Early pubic/axillary hair growth Severe acne Hirsutism & oligomenorrhea in girls ↑ Growth velocity & bone age ------> ↑ 17-Hydroxyprogesterone level *** NO bil labial masses !
dx:
- > 17-OHP response : ACTH stimulation test
Rx:
Hydrocortisone
labial adhesion ?
- > age < 2 yr @@
- > not asso with lichenification
- > NO perianal inv
streptococcal dermatitis ?
- > superinfection in patients with a constant irritant (eg, bathing suit)
- > perianal pruritis and anal fissures.
- > bright, erythematous perianal rash with sharply demarcated borders
*** NOT thin, white skin.
Zika virus ?
SS RNA Flavivirus
- > Transplacental transmission to fetus
- > Targets neural progenitor cells
sym:
- > SEVERE Microcephaly !!!
- > craniofacial disproportion
- > neuro abnormal (eg, spasticity, seizures)
- > Ocular abnormalities
dx:
- > intracrainial Calcifications ( tix necrosis)
- > ventriculomegaly, cortical thinning
Zika RNA detection
5-alpha-reductase deficiency
sym?
–> 46,XY genotype
- > Impaired testo –> DHT conversion
- > Impaired virilization during embryogenesis
lab:
NORMAL male testosterone & estrogen levels
sym:
- > Male internal genitalia (eg, testes, vas deferens)
——> NO BREAST !!!!!! testo bind to breast androgen receptor : inhibits breast tix proliferation
-> Female external genitalia (eg, blind-ending vagina)
-> Phenotypically female at birth
Virilization at puberty (↑ testosterone): deep voice
Clitoromegaly: undescended testes ( bil labial masses, clitoris protruding from clitoral hood)
Increased muscle mass
Male-pattern hair development
Nodulocystic acne
normal preg changes physio?
Physio: ↑ Renal blood flow ↑ GFR ↑ Renal basement membrane permeability -> inc CO + BP inc
lab: ↓ Serum BUN ↓ Serum creatinine ----> inc GFR excretion ! ↑ Renal protein excretion -> pt dec / normal
asthma in preg?
resp changes in preg:
- > inc TV, inc Min vent
- > dec RV
–> resp alkalosis comp met acidosis ( inc HCO3 loss)
rx:
- > acute: beta agonist short acting
- > sys steroids for acute exacerbation
vasa previa
RF?
sym?
rx?
—-> Fetal vessels overlying the cervix: prone to tear + rupture of mem/ contractions
RF: Placenta previa Multiple gestations IVF Succenturiate placental lobe
sym:
-> PAINLESS vag bleeding with ROM or contractions
- > FHR: bradycardia, sinusoidal pattern
- > Fetal exsanguination & demise
Rx:
ER C/S
chronic HTN pregnancy
rx?
- > extended release Nifedipine : ccb
- > labetalol
- > hydralazine
- > methyldopa
*** atenolol: asso LBW
Short interpregnancy interval
comp?
-> <6-18 months from delivery to next pregnancy
comp:
- > Maternal anemia
- > PPROM
- > Preterm delivery
- > Low birth weight
postpartum period
normal ?
NORMAL finding:
-> Transient rigors/chills: dec Estrogen + progesterone
- > Peripheral edema
- > Lochia rubra: shedding uterine decidua + blood
- > Uterine contraction & involution: inc OXYTOXIN
- > Breast engorgement : inc Prolactin
Routine care: -> Rooming-in/lactation support -> Serial exam for uterine atony/bleeding -> Perineal care -> Voiding trial -> Pain management
diabetic nephropathy in preg?
- -> inc Pnuria
- > elev cr
- > htn
< 20 GA
Pituitary apoplexy
sym?
- > spontaneous hemorrhage into the pituitary gland
- > common in :pituitary adenoma.
sym:
-> acute headache, visual field defects, and decreased visual acuity.
HBV vaccine
mother + neonate ?
vaccine during preg is OK : KILLED vaccine
Infants of mothers with hepatitis B
- –> can safely breastfeed
- —> if administration of the HB Ig + HB vaccination series
- > rxm: breast feeding ok!!
infant: passive HBIg + active immunication HB vaccine
Breastfeeding contraindications
Maternal:
- > Active untreated TB
- > HIV infection*
- > Herpetic breast lesions
- > Active varicella infection
- > CMT or radiation therapy
- > Active substance use disorder
Infant:
Galactosemia
plugged duct breast?
-> focal tenderness + firmness +/- erythema
NO fever
Down syn:
Down syndrome + VACTERL :
Vertebral, Anal atresia Cardiac, Tracheoesophageal fistula Esophageal atresia Renal Limb association
- -> duodenal atresia requires evaluation for other fetal malformations (eg, VSD)
- > thickened nuchal folds
turner syn 45 xo?
horseshoe kidneys-> ob causing oligohydramnios (not polyhydramnios).
-> cardiac defects (eg, coarctation of the aorta)
- > cystic hygromas
- > hydrops fetalis.
edward syn trisomy 18 ?
diaphragmatic hernia
- > rocker-bottom feet
- > clenched hands with overlapping finger
trisomy 13 patau syn?
midline defects (eg, microcephaly, cleft lip/palate, omphalocele).
