Obstetric and Gynecology Flashcards
What syndrome can cause amenorrhea after birth?
Sheehan Syndrome - postpartum pituitary necrosis after significant PPH
What hormone is deficient in Kallmann Syndrome?
Congenital GnRH deficiency
Excluding pregnancy, what is the epidemiology of secondary amenorrhea?
Ovarian 40%
Hypothalamus 35%
Pituitary 19%
Uterine 5%
Other 1%
OH PU
What syndrome should anosmia with amenorrhea make you think of?
Kallmann
A patient with galactorrhea and amenorrhea should make you think of?
Pituitary changes
Serum level of prolactin usually correlates with the size of a tumor
Dysmenorrhea aggravating factors
- Presentation at age < 30
- Menarche before age 12
- Longer cycles/duration of bleeding
- Heavy smoking
- Nulliparity
If an ultrasound of the uterus shows abnormal or absence then you should consider which conditions as a cause for amenorrhea?
Mullerian agenesis or androgen insensitivity syndromes
If a patient has secondary sex characteristics but presents with amenorrhea, negative pregnancy test and high FSH/LH then what causal conditions should be considered?
Turner
Swyer
Primary ovarian insufficiency
What prostaglandins are associated with prolonged myometrial uterine contractions and dysmenorrhea?
PGF2a , PGE2
Condition associated with dysmenorrhea and adnexal tenderness, cul de sac nodularity or tenderness
Endometriosis
Condition associated with dysmenorrhea and bulky, tender uterus
Adenomyosis
Condition associated with dysmenorrhea and enlarged uterus
Leiomyoma (uterine fibroids)
Most common gynecological tumor
Ddx: adenomyosis, PID, endometriosis
If a patient presents with dysmenorrhea that is not resolved with NSAIDs/OCPs, has a suspicious hx or an abnormal physical exam what step should be taken next?
Pelvic U/S
What medication is used for primary dysmenorrhea treatment?
PG synthetase inhibitors
naproxen, ibuprofen, mefenamic acid, and indomethacin
3-6 month trial, if pain continues consider secondary dysmenorrhea
What tests should you do for secondary dysmenorrhea investigation?
Urinalysis (UTI)
Cervical culture (STI)
Pelvic U/S (bHCG, ectopic, cysts, fibroids, IUD)
Hysterosalpingogram (polyps, leiomyoma, congenital abnormality)
Diagnostic laparoscopy
Hysteroscopy
What is the normal amount of blood loss in a period?
20-80 mL/cycle
What changes in hormones cause anovulatory cycles in perimenopausal women?
↓ # ovarian follicle pool
↓ inhibin
↑ FSH secretion
↓ FSH receptors in a decreased cohort of follicles
poor dominant follicle development
Intermenstrual bleeding differential
Infection: cervicitis, endometriosis, vaginitis, STI
Benign growth: cervical/endometrial polyp, fibroid, ectropion
Malignant growth: uterine, cervical, vaginal, vulvar, ovarian
Vulvovaginal: infection, dermatoses, system (Crohn’s)
Abnormal vaginal bleeding in a post menopausal woman
Endometrial CA until proven otherwise
If you see uterine enlargement on pelvic U/S of a non pregnant patient with abnormal vaginal bleeding what are your next steps?
Transvaginal U/S or sonohysterography to look for adenomyosis, malignancy or benign growths
If pt is menopausal do endometrial biopsy to r/o endo ca
What are the most clinically important aspects in the evaluation of pts with abnormal vaginal bleeding
Prenancy status
Hemodynamic status
What are the indications for ultrasound in a pt with abnormal vaginal bleeding
Uterine enlargement identified through pelvic exam
Any pregnant woman
Persistent vaginal bleeding
What is contraindicated in a >20 wk pregnant pt with bleeding?
Pelvic exam UNTIL U/S has excluded placenta previa
Indications for endometrial biopsy or cytological studies
- Women > 40 with abnormal vaginal bleeding
- ANY post menopausal bleeding
- High risk of endo ca ie: no kids, hx infertility, BMI>30, PCOS, hx of infrequent periods, fmhx
- Tamoxifen use
- Persistent bleeding despite 3 mo course of meds
- Post menopausal without bleeding but WITH >11 mm endo thickness on TVUS
- Previously diagnosied endometrial hyperplasia or abnormal pap with atypical cells favoring endometrial origin
What to do if sexual abuse is suspected as cause of abnormal vaginal bleeding?
Reporting is up to the victim unless they are a child.
MD MUST report abuse of children
Victim must give informed consent before collection of samples
Store samples securely even if pt changes their mind
How to differential PMDD vs PMS?
In PMDD mood systems are dominant (low self esteem, moodiness, paranoid, sadness, etc) and there is difficulty with day to day functioning for > 2 consecutive cycles in the premenstrual phase
In PMS the symptoms do not affect day to day living and all symptoms are possible
PMDD is the most severe form of PMS
PMDD DSMV critera
Sx occur in the week before menses, stop a few days after onsent and are absent the week after
Must interefere with ADL
Not an exacerbation of other disorder
At least 2 consecutive cycles
FIVE of the following must be present:
ONE of:
Depressed mood, hopelessness, self deprecating thoughts
Marked anxiety/tension
Affective lability
Persistent anger or irritability, increased Interpersonal conflict
+ ANY combination of the following:
Social withdrawal
Trouble concentrating
Lethargic
Increased apetite/cravings
Hypersomnia or insomnia
Overwhelmed
Other physical sx (breast tenderness, abdo bloat, headache, joint point)
What supplements can you recommend for PMS symptoms?
CaCO3 (1,200 mg)—to ↓ bloating, depression, and
aches
Mg2+ supplementation (50–100 mg b.i.d.)—to ↓ pain, fluid retention, and improve mood
Vit E (400 IU)—may ↓ breast tenderness
Absolute contraindications to OCP
<6 wks postpartum if breast feeding
breast ca
smoker > 35 to or > 15 cig/d
uncontrolled HTN
venous thromboembolism (current or historical)
ischemic heart disease
valvular hear disease
diabetes with retinopathy/neuropathy/nephropathy
migraines with focal neurological symptoms
severe cirrhosis
liver tumors
undiagnosed vaginal bleeding
thrombophilia
pregnant
Who would you use progesterone only contraception in?
Pts with sensitivity or contraindication to estrogen
> 35 yo and smoker
Previous migraines
Breast feeding
Endometriosis
Sickle cell
History of blood clots
Anticonvulsant rx
Diffiuclty complying with daily pill
What lab testing or exams need to be done before prescribing OCP?
None are required
What are the risks of Depot medroxyprogesterone acetate (DMPA)?
Decrease bone mass density
Delayed return of fertility (9 mo delay before full fertility returned)
80% of miscarriages occur when?
Within the first 12 weeks of pregnancy
Risk factors for pregnancy loss
- GA (↑ risk with earlier age)
- Advanced maternal age
- Previous miscarriage
- Smoking
- EtOH
- Cocaine use
- > 1 alcoholic drink/d
- Caffeine (> 375 mg of caffeine)
Name the two methods of abortion used in the first trimester?
Vacuum curettage (D&C) and misoprostol (PGE1 analog)
Name three methods of abortion useful in the second trimester?
Dilation and evacuation, labor induction with misoprostol vaginally (100 mg) or dinoprostone, oxytocin (17-24 weeks)
What is the physicians duty in the case of abortions?
They are not required to perform abortions but have a duty to share all information and options with their patients and make appropriate arrangments
What are risk factors for early menopause?
Smoking, chemo, radiation, hysterctomy, epilepsy, nulliparity
What is the main cause of deaths in post menopausal women?
Heart disease
What factors have no bearing on age of menopause?
OCP use, age of menarche, ethnicity, marital status, improved nutrition
When would you do a spine XR in post menopausal women?
> 6 cm loss of height, acute incapacitating back pain, prospective height loss > 2 cm
A T score of -2.5 or lower indicates what?
Osteoporosis
A T score of -1.0 and -2.5 is indicative of what?
Osteopenia
What dose of vitamin D and Ca should post menopausal women be taking?
Vitamin D 800 IU/day
Ca2+ 1.5 g/day
When would you give estrogen only HRT?
Postmenopausal woman without uterus.
If you give to a woman with intact uterus you increase her risk of endometrial carcinoma due to hyperplasia
Who is progesterone only HRT contraidicated in?
Do not give progesterone only therapy to a patient with breast cancer
Progesterone will stimulate the growth
Alternatives: tamoxifen or aromatase inhibitors which block the effects of estrogen on breast tissue (Letrozole, Anastrozole, Exemestane)
What medical treatments are used for the vasomotor symptoms of menopause?
Venlafaxine, SSRIs, gabapentin, clonidine, bellergal, estrogen therapy, estrogen/progesterone therapy
What effect does estrogen have on bones and calcium?
Decreases bone resorption, increases intestine Ca absorption, decreases renal Ca excretion
Contraindications to estrogen therapy
CULT
Cancer
Undiagnosed vaginal bleeding
Liver disease (acute)
Thromboembolic disease (active)
Contraindications to progesterone therapy
PUB
Pregnancy
Undiagnosed vaginal bleeding
Breast cancer
Relative contraindications to combined HRT
BAMIG
History of breast cancer
Atypical hyperplasia of the breast, fibroids
Migraines
Increased triglycerides
Active gall bladder disease
What are the treatments for bacterial vaginitis?
Metronidazole 500 mg po bid x 7 days or 5 gram pv qd x 5 days, clindamycin 5 grams pv x 7 days
What are the treatments for vaginal candidiasis?
Fluconazole 150 mg po once
Clotrimazole 500 mg pv once or 5 g pv x 3 days
What are the treatments for vaginal trichomoniasis?
Metronidazole 2 gram po once or 500 mg po bid x 7 days
MUST treat sexual partners simultaneously to prevent reinfection!
What is an important consideration in the treatment of vaginal trichomoniasis?
MUST treat sexual partners simultaneously to prevent reinfection
What is an important consideration for bacterial vaginosis in pregnant women?
Increases the risk of preterm birth
Important to treat in pregnancy
What is an important consideration of vaginal trichomoniasis in pregnany women?
Facilitates HIV transmission and associated with premature rupture of membranes
Who should be tested for G/C?
Seuxally active and less than 25 yo
Fever with lower abdo pain
Asymptomatic sexual partner
Other STI diagnosis
Pt with a new or more than one sexual partner
Which STIs are mandatory to report?
Chlamydia, gonorrhea, chancroid, syphilis, genital herpes, hepatitis B, trichomoniasis, HIV
What kind of testing for chlamydia should be done in children or circumstances with potential legal implications?
Throat and/or rectal culture
What is the most appropriate treatment for gonorrhea in pregnancy?
Cefixime 800 mg po once
What is the most appropriate treatment for chlamydia in pregnancy?
Azithromycin 1 gram po once
Treatment for gonorrhea
- Cefixime (safe in pregnancy)
- Ceftriaxone + Azithromycin or Doxycycline
- Azithromycin or Spectinomycin + COTREATMENT FOR CHLAMYDIA
Treatment for chlamydia
- Macrolide (azithromycin) or doxycycline
- Erythromycin
Gold standard test for chlamydia
PCR or nucleic acid amplification test (NAAT) is the gold standard
When should all gonorrhea/chlamydia patients be retested?
ALL cases 6 months post treatment
What situations would you retest a patient undergoing chlamydia treatment early?
Retrest them within 3-4 weeks (as opposed to 6 months) if you are questioning their compliance, they are retreated with a non recommended treatment or they are pregnant
What situations would you retest a patient undergoing gonorrhea treatment early?
Retest within 3-7 days after initiation of treatment:
If they have pharyngeal infection
Patients treated with non recommended regiment
If you suspect treatment failure
If you are questioning their compliance
Reexposure to the untreated partner
PID
Disseminated infection
Pregnant
Painless genital ulcer with microscopy showing spirochetes
Primary syphilis
Chancre
Resolves 2-8 weeks
Rash of palms and soles, fever, condyloma lata, alopecia, uveitis, retinitis
Secondary syphilis
Screen initially with VDRL and RPR
Small and irregular pupils that have little to no constriction to light but constricts briskly to near targets
Argyll Robertson pupil
Prostitutes pupil
Accomodate but don’t react
Late syphilis presentation (tertiary)
What are the treatment options for syphilis?
Penicillin G (better in pregnancy) OR doxycycline (bad in pregnancy)
What are latent signs of syphilis?
Aortic aneurysm, aortic regurgitation, coronary artery ostial stenosis
What stages of syphilis are considered infectious?
Primary, secondary and early latent (<1 year)
60% risk of transmission
Painful genital ulcers
Haemophilus ducreyi (chancroid) and herpes
What partners do you inform when diagnosed with HSV?
Sexual partners from preceding 60 days before symptoms due to asymptomatic shedding risk
What is the greatest risk factor for neonatal herpes?
Primary maternal genital HSV 1 or 2
Gram stain of GN coccobacilli
with “school of fish” pattern
H ducreyi chancroid
Reportable STI
Most common infectious cause of lower abdominal pain in women
Pelvic inflammatory disease
Most common causative agents in PID
C/G
E coli
M. genitalium
Others (rare): Peptostreptococcus, G. vaginalis, Prevotella, Bacteroides, Streptococcus, H. influenza, T. vaginalis,, M. hominis
PID minimum triad
Lower abdominal pain + one of the following:
Adnexal tenderness
Cervical motion tenderness
Uterine tenderness
What is Fitz-Hugh-Curtis Syndrome
Perihepatitis resulting in adhesions between the liver capsule and the abdo wall. Perihepatitis resolves with Rx of PID.
Infertility is more common with which STI
Gonrorhea if there is delay of treatment
75% risk of tubal damage in third episode of PID
Gold standard for diagnosing PID
Laparoscopy demonstrating abnormalities consistent with PID such as fallopian tube erythema or mucopurulent exudates
If a patient with PID wants their IUD removed what would have to happen first?
There should be at least 2 doses of AB given first
When would you admit a patient with PID?
Pregnant
Appendicitis cannot be excluded
Child
Poorly compliant
Cannot tolerate oral treatment
If an abcess (pelvic or tubo-ovarian) is suspected
Immunocompromised
Diagnosis is uncertain
Severely ill such a vomitting, fever, pain
HIV positive
How do you treat a tubo-ovarian abscess once you have ruled out risk of rupture?
Cefotetan + doxy
Cefoxitin + doxy
Clindamycin + gentamycin then doxy
COnsider adding metronidazole to all above treatments
If does not respond in 2-3 days then consider guided drainage (transvaginal or transcutaneous) or surgery
If does respond in 2-3 days then consider AB for ~2 weeks
Most common type of cervical carcinoma
Squamous cell carcinoma 90%
Adenocarcinoma 10%
High risk HPV subtypes
16, 18, 45, 56
Low risk HPV subtypes
6, 11, 41, 44
Second most common cancer in women < 50 years old
Cerivcal cancer
Median age of diagnosis is 47
Most common STI
HPV
Condoms do not fully protect against transmission
Can be transmitted without penetration
75% of Canadians have had one or more HPV infection
What is the preferred method for obtaining cervical cytology?
Liquid based cytology pap smear
What are the guidelines for pap smear screening?
- Start within 3 years of initiating sexual activity or age 21, whichever is later
- Do anually until thre are 3 consecutive negative results
- Then do every 2-3 years until age 69 and discontinue if the last 3 were normal
- If there is 5 year break inbetween last one then begin annually until there are 3 consecutive normal ones then continue like normal
- If has HIV then do annually
- Stop if they have hysterectomy for benign reasons and no hx of dysplasia
What are the guidelines for pap smear screening?
- Start within 3 years of initiating sexual activity or age 21, whichever is later
- Do annually until there are 3 consecutive negative results
- Then do every 2-3 years until age 69 and discontinue if the last 3 were normal
- If there is 5 year break inbetween last one then begin annually until there are 3 consecutive normal ones then continue like normal
- If has HIV then do annually
- Stop if they have hysterectomy for benign reasons and no hx of dysplasia
When are colposcopies done?
They provide magnification and illumination of the cervix to:
Further assess abnormalities of the cervix
Rule out invasive disease
Follow up after treatment
Biopsy can be performed during procedure and carry an accuracy of 85-95%
Next step for > 30 yo patient with atypical squamous cells of uncertain
significance
Do HPV DNA testing then colposcopy
What pap results would you do colposcopy on as the next step?
ASC-H
ASCUS and > 30 yo
LSIL and 6 months later pap shows higher grade change
Persistent ASCUS x 2 years or higher grade changes
AGUS
HSIL
Squamous carcinoma
Adenocarcinoma
Other neoplasm
What pap results do you just retest later for?
Normal
ASCUS but < 30 yo = repeat q6m x 2 years
What strains does the HPV vaccine protect against?
6, 11, 16, 18
When is HPV vaccine given?
0
2 month
6 month
Should ideally be started before the onset of sexual activity
Age 9 - 26 male and female
Not recommended < 9 yo
CAN be administered over 26 yo but not often recommended because by that age most adults have been exposed to it
What conditions does the HPV vaccine prevent?
Adenocarcinoma in situ
Anal intraepithelial neoplasia
Anal ca
Anogenital warts
Cervical ca
Vulvar or vaginal ca
What are the typical signs and symptoms for cervical carcinoma?
Postcoital bleeding
Malodorous or bloody dischage
Leg edema
Deep pelvic pain
Sciatica
How often should a PHE be performed for a patient with no apparent health problems?
Every 2-3 years
CIN I
Invasive carcinoma of only the cervix
Rx: Conization or radical hysterectomy +- radiation depending on the lesion size
CIN II
Cancer has spread beyond the cervix, but not to the pelvic wall or lower third of the vagina
Rx: Radiation therapy +- concurrent chemotherapy, followed by brachytherapy (internal radiation)
CIN III
Cancer has spread to the pelvic wall and/or lower third of the vagina and may be blocking the ureters
Rx: Radiation +- chemoradiation therapy, followed by brachytherapy or hysterectomy
CIN III
Cancer has spread to the pelvic wall and/or lower third of the vagina and may be blocking the ureters
Rx: Radiation +- chemoradiation therapy, followed by brachytherapy or hysterectomy
CIN IV
4
Cancer has spread to other parts of the body, such as the bladder or rectum
Rx: Radiation therapy +- chemotherapy and/or surgery (palliative care)
How long does it normally take from the detection of cytological abnormalities on a pap to change to invasive carcinoma?
~ 15 - 20 years
Signs and symptoms of sepsis
Fever or hypothermia
Tachycardia
Hypotension
Tachypnea
Altered mental status or confusion
Abdominal pain or distension
Nausea and vomiting
Diarrhea or constipation
Skin rash or mottling
Decreased urine output
Hypoxemia or respiratory distress
How would you rule out ectopic pregnancy in a patient with pelvic mass and + bHCG?
Do transvaginal ultrassound first then quantitative bHCG
It shold not double in 28 hours
How would you investigate an ovarian cyst in a premenopausal woman that is less than 5 cm in size?
Serial U/S q3m
If the size decreases then do U/S q4-6 mo x 1 year then q1y
If the size increases then refer to gynecology for ex lap +- cystectomy
If the size stays the same then do an OCP trial to prevent the formation of new cysts then follow clinically
How would you investigate an ovarian cyst in a premenopausal woman that is greater than 5 cm in size?
Refer to gynecology for ex lap and/or cystectomy
How would you investigate an ovarian cyst in a post menopausal woman?
If all else is normal and the mass is less than 5 cm then do U/S q3m with Ca 125
If all else is normal and the mass is greater than 5 cm send to gynecology
If there are malignant features on ultrasound then refer to gynecology
Female patient with sudden onset of severe unilateral lower abdominal pain, nausea, and vomiting, with or without a palpable pelvic mass
Think ovarian torsion
Do transvaginal U/S if pt is not pregnant
Do laparoscopy vs laparotomy
Medical emergency
What is important to remember about a leiomyoma? What might the uterus exam findings be?
This is a benign tumor of the uterus that can present with heavy menstrual bleeding, pelvic pressure, and infertility
May be an enlarged uterus that is irregularly shaped with a firm consistency on exam
Ultrasound may show multiple well-circumscribed masses.
“Leiomyomas, oh what a sight,
Uterus enlarged, not quite right.
Irregular contour, nodules here and there,
Firm consistency, handle with care.”
What is adenomyosis? How might a patient with this present?
Condition where endometrial tissue grows within the myometrium of the uterus
May present with heavy menstrual bleeding, dysmenorrhea, and a boggy, tender uterus on exam
Imaging may show a thickened, globular uterus
How might a patient with ovarian malignancy present? What would their imaging studies show?
Ovarian malignancy can present with abdominal distension, pain, and a palpable pelvic mass
Imaging may show a complex cystic mass with solid components
Do CA125 levels and refer to gynecology
Treatment for symptomatic uterine fibroids in a patient that wishes to retain their fertility?
Low dose OCP
Progestational agent
SPRM
GnRH analogue like Leuprolide
Danazol
How does Leuprolide work? What is an important side effect to remember?
GnRH agonist that stops E and P production by the ovaries that causes temporary menopause like state that can shrink fibroids
Do not use for more than ~6 mo because increases risk of osteoporosis
Remember that it can cause an initial flare by increasing LH/FSH transiently which causes increase in testosterone in men (ie: increased bone pain in prostate cancer) or estrogen in women (ie: increased pain with endometriosis) but this is TRANSIENT
What diagnostic imaging is done in pelvic masses?
- Ultrasound: first choice, can tell you if the mass is cystic vs solid, where it is and how big it is. You can check for ascites. It is safer in pregnancy
- CT: Suboptimal for ovaries, good for all other organs and lymph nodes, good for retroperitineum
- MRI: Good for soft tissue lesions, ok in pregnancy
- Others: abdominal XR, IV pyelogram
What should you suspect in a patient with cervical motion tenderness?
May indicate pelvic inflammatory disease
You want to investigate quickly to prevent complications such as chronic pelvic pain, infertility, ectopic pregnancy
What findings would you expect in a patient with a benign ovarian mass?
Reproductive age pt
Unilateral mass
Less than 5 cm big
Cystic only
Smooth in shape
Movable
Small amount of physiological free fluid
What findings would you expect in a patient with a malignant ovarian mass?
Prepubertal, perimenopausal, postmenopausal
Bilateral mass
Bigger than 5 cm and rapidly increasing in size in less than 6 weeks or larger than 10 cm in size on discovery
Solid or mixed consistency with multiple or thick septae
Irregular shape with papillary projections
Fixed mobility
Increased ascites (free fluid in pelvic or abdoment) and increased vascularity
Which ovarian masses are considered to be malignant until proven otherwise?
ANY ovarian mass in a postmenopausal woman or any solid mass in childhood
OLD AND YOUNG
What pelvic masses do you refer on?
- Persistent > 2 periods in reproductive age women
- Any postmenopausal mass
- > 5 cm mass
- Nodular, fixed, solid mass
- Mass with ascites
- Increased CA125
- Suspected abnormal pregnancy
- Mass requiring surgery
Which pelvic masses presents with increased AFP?
Germ cell tumors (may also have increased hCG), dermoids, pregnancy, HCC
Which pelvic masses present with increased LDH?
Dysgerminomas (rare malignant germ cell tumor of the ovary)
Prompt diagnosis and treatment is essential
hCG levels may also be elevated
Which ovarian masses present with increased CA125?
Epithelial cell ovarian tumors
Fibroids
PID
Endometriosis
Cirrhosis
Adenomyosis
Pregnancy
Appendicitis
Breast/lung/ovary/fallopian tube/colon ca
Pancreatitis
Renal failure
Ascites
Which type of ovarian carcinoma is most common?
Epithelial cell tumors
80% of ovarian ca
How do you investigate epithelial cell tumors of the ovary?
MC ovarian ca
No reliable screening available
Diagnose with surgical staging
Treat with surgical debulking and chemo
Follow progress with CA 125 levels
If BRCA1/2 carrier than recommend prophylactic bilateral salpingectomy +- oophorectomy when theyre done having babies
Which type of pelvic pain is potentially life threatening?
Acute which is less than 6 months
What physical exams are important in a patient with pelvic pain who is hemodynamically stable?
- Vitals
- Abdominal exam
- Pelvic exam
- Digital RE
- MSK exam
- Pain diary
What exams are important in a patient with pelvic pain who is hemodynamically stable?
- Vitals
- Abdominal exam
- Pelvic exam
- Digital RE
- MSK exam
- Pain diary
What contraceptive method is contraindicated in poorly controlled diabetes and migraines?
Combined hormonal contraceptives are not recommended as they may increase risk of cardiovascular event and stroke
They are also bad in migraines because may increase risk of stroke
Give these patients progestin only pills
Who should combined estrogen/progestin combination pills not be used in?
Should not use in patients with migraine WITH AURA
Increases risk of stroke
What is the difference to remember in giving OCP to patients with migraine with and without aura?
Without aura and < 35 yo combined estrogen/progestin has advantages that outweigh the risks
With aura and > 35 yo combined pill should not be recommended unless there are contraindicated to other methods
Copper IUD are fine
What are the surgical treatments for chronic pelvic pain that does not respond to meds, PT or psychotherapy?
- Laparascopic laser ablation
- Laparoscopic adhesiolysis
- Presacral neurectomy (superior hypogastic plexus excision)
What are the three most common locations for an ectopic pregnancy?
Ampullary, isthmus, fimbrial
Then ovarian, interstitial, abdominal, cervical
What steps do you take if you suspect an ectopic pregnancy?
- Test bHCG
- If bHCG is >1500 then do TVUS
- If there is an extrauterine sac +- fetal cardiac activity or no intrauterine sac = ECTOPIC
- If there is a normal uterine pregnancy then reevaluate in 2-3 days
- Test bHCG
- If bHCG < 1500 = pregnancy of unknown location
- Retest bHCG in TWO DAYS
- If it increases do TVUS
- If it doubles do U/S to confirm pregnancy
- If it stays the same watch for EP or miscarriage
What are risk factors for ectopic pregnancy?
Previous EP
Current IUD
Hx PID
Previous tube surgery
In utero DES
Infertility
Smoker
Uterine strictures including fibroids or adhesions
What pharmaceutical treatment is given for ectopic pregnancy? How does it work?
Methotrexate - folic acid antagonist that stops DNA synthesis and cell reproduction
Single IM dose 50 mg/m2 of body surface area
Contraindications: Breast feeding, liver disese, blood dyscrasia, renal dysfunction
What are the surgical options for ectopic pregnancy?
Linear salpingostomy or salpingectomy
What composes the muscular pelvic floor?
Levator ani (puborectalis, pubococcygeus, iliococcygeus) and the coccygeus muscles
What are the risk factors for pelvic prolapse?
Pregnancy, delivery, big baby, perineal laceration (3&4), hysterectomy, low estrogen, increased abdominal pressure (smoking, obese, chronic cough, constipation, weight lifter, ascites), pelvic mass, connective tissue disorder, genetics
What are the stages of prolapse?
- Stage 0: no prolapse
- Stage I: most distal prolapse is 1 cm above the hymen.
- Stage II: most distal prolapse between 1 cm above or below the hymen
- Stage III: most distal prolapse > 1 cm distal to the hymen
- Stage IV: total prolapse
What imaging is necessary in prolapse?
None is necessary unless procidentia (stage 5 total prolapse) present and you are trying to rule out urinary retention
Steps to evaluate a cystocele?
Herniation of the bladder with associated descent of the anterior vaginal segment
Do UTI screen
Do postvoid residual
Refer to gyn
What are important parts of the physical exam of prolapse?
Inspect vulva/vagina for erosion/ulceration
Estrogen status
Examine aspects of vaginal support with speculum
Standing straining exam
Stress incontinence exam
Digital assessment of pelvic muscle and anal sphincter baseline and voluntary contraction tone
Consider rectovaginal exam to detect enterocele
Consider lower extremity neuromuscular exam
All patients with defecatory dysfunction should be evaluated for?
GI dysfunction
Give age appropriate screening for colorectal cancer
In institutionalized geriatic patients what syndrome generally resolves after removal of fecal impactions?
Urinary incontinence
What is the most common type of incontience in ambulatory women?
Stress 29-75%
Detrusor overactivity 7-33%
What medications cause urinary retention?
6 main ones
Narcotics/opioids, anticholinergics, antidepressants, antipsychotics, alpha agonists, calcium channel blockers
Think: a lot of psych meds
What investigations are done in incontience?
PVR
Urinalysis
Consider serum urea, creatinine, glucose, calcium
What is the hallmark of diagnosis for urge incontience?
Involuntary bladder contraction ie detrusor overactivity
What lifestyle interventions can help with stress incontinence?
SI is involuntary leakage during effort (sneeze,cough, exercise, etc)
Try:
* Weight loss, decreased caffieine and fluid intake, quit smoking, decrease exercise, timed voiding
* Pelvic muscle exercises (Kegels)
Name five lifestyle factors associated with infertility
Obese
Smoker
Alcohol use
Drug use
Caffeine
What infectious disease testing is essential in planning for pregnancy?
HIV, rubella IgG, varicella, syphilis, hepatits B, gonorrhea/chlamydia
What immunizations should be updated prior to conception?
Hepatitis B, rubella, varicella, Tdap, HPV, influenza
When is RhoGAM given to Rh- women?
Week 28
What meds can cause too little amniotic fluid (oligohydraminos)?
ACEi and NSAIDs
Most common etiology of polyhydraminos
Maternal DM (preexisting and gestational)
Idiopathic
What is a normal fetal kick count?
When should fetal movement be noticed?
Normal is about 10 per hour but varies
Less than 6 movements in 2 hours should be investigated
Fetal movement should be noticable at the late 2nd to 3rd trimester 18-40 weeks
Do NST +- BPP
Steps for rescuscitation of post partum hemorrhage
Large bore IV
Intravenous fluids
O2 using mask
Cross and type 4 units of PRBC
Monitor vitals (BP, HR, SaO2, RR)
How to assess etiology of post partum hemorrhage?
Tone (uterine atony), tissue (retained placental tissue or blood clots), trauma (lacerations), thrombin (hx of coagulopathy)
What is normal estimated blood loss after delivery?
500 mL for vaginal
1000 mL for C-section
How many days after delivery do postpartum blues last?
Begin day 3 and end around day 10
Due to life adjustments and hormones
Self limiting
Give supportive care
A patient presents for her post partum check. What topics should be discussed?
- Amount of vaginal bleeding
- Pain resolution
- Bowel/bladder function
- Mood/support
- Contraception plans
- Breast-feeding/bottle-feeding
What are irregular contractions not associated with cervical dilation or descent of fetus?
Braxton Hicks
What is the average duration of the second stage of labor?
Time between full cervical dilation and delivery
In new mom: ~50 minutes - 2 hours
In old mom: ~20 minutes - 1 hour
What is the average duration of the third stage of labor?
Time between delivery of baby to placenta
~10 minutes - 30 minutes
What is the average duration of the first stage of labor?
Time between onset of labor to full cervical dilation (10 centimeters)
Latent phase: onset of contractions to 3-4cm dilation
In new mom: ~6.5 h - 20 h
In old mom: ~4.5 h - 15 h
Active phase: Increased cervical dilation with regular contractions and descent of fetus
In new mom: Dilate 1.2 cm/hour
In old mom: Dilate 1.5 cm/hour
Total:
In new mom ~10 h
In old mom: ~8 h
How do you manage an abnormal fetal heart rate tracing?
- Recheck
- Backup
- Change maternal position (left lateral decubitis)
- Give 100% O2 to mother via mask
- Stop augmentation of labor
- Do fetal scalp stimulation
- Rule out causes of uteroplacental deficiency
- Correct maternal hypotension with IV fluids and ephedrine
- Rupture sac (amniotomy)
- Fetal scalp electrode
- Fetal scalp blood pH ( >7.25 normal, <7.20 acidosis)
- Amnioinfusion to protect cord from compression
What antiobiotics are used to treat GBS?
Penicillin G 5 mill units IV loading then 2.5 mill units IV q4h
IF PENICILLIN ALLERGY THEN USE ALTERNATIVE:
Cefazolin 2 gram loading then 1 gram q8h
IF PENICILLIN ALLERGY AND PREVIOUS GBC DOCUMENTED THEN USE:
Clindamycin 900 mg IV q8h
IF PENICILLIN ALLERGY WITH GBS RESISTANCE TO CLIND THEN USE:
Vanco 1 grm IV q12h
What fluid must be given before epidural?
Hydrate with dextrose free isotonic IV fluid before initation
Vaccines recommended for pregnant women
- inactivated influenza vaccine
- acellular pertussis vaccine (given as tetanus toxoid, diphtheria toxoid, acellular pertussis vaccine) irrespective of history
- hepatitis B vaccine if susceptible and with ongoing exposure risks
- hepatitis A vaccine if a close contact of a person with hepatitis A or if travelling to an endemic area
- meningococcal vaccine in an outbreak setting or post-exposure, or if indicated by medical condition
- pneumococcal polysaccharide vaccine with or without conjugate vaccine if indicated by medical condition
- any other inactivated vaccine if indicated by exposure (e.g. rabies), travel (e.g. inactivated typhoid vaccine) or by medical condition (e.g. asplenia)
Recommended contraceptives in order of effectiveness
- LARCs, specifically the IUD or IUS.
- Hormonal methods: Oral contraceptives, the transdermal patch, the vaginal ring and injectable contraceptives (e.g., DMPA).
- Methods used at the time of intercourse: Male and female condoms, diaphragms, cervical caps, sponges and spermicide
For patients who are uncomfortable with LARCs, using a hormonal method and an in-the-moment method together is almost as effective
What is the most effective emergency contraception?
Copper IUD - can be inserted up to 7 days postcoitus, better than oral pills
Modifiable risk factors for otitis media
Lack of breastfeeding, daycare attendance, household crowding, exposure to cigarette smoke or air pollution, pacifer use
Non-modifable: young age, family history of OM, prematurity, orofacial abnormalities,
immunodefciencies, Down syndrome, race, and ethnicity
