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Study Notes Obstetrics Gynecology

Study Notes Obstetrics Gynecology

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Study Notes Obstetrics Gynecology
Study Notes Obstetrics Gynecology

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07/15/2014

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Study Notes – Obstetrics & GynecologyJames Lamberg28Jul2010DO NOT DISTRIBUTE - 1 -
Textbooks
: Essentials of Ob/Gyn, Ob/Gyn Secrets, First Aid for Ob/Gyn Clerkship
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Common Problems in Obstetrics & Gynecology
Pregnancy: Prenatal and Antepartum Care, Normal Labor and Delivery patterns, Caesarian Section, Postpartumhemorrhage, Postpartum infectionComplications: Diabetes Mellitus, UTI, Pre-term labor, Third trimester bleeding, Hypertension, pre-eclampsia andeclampsia, Multiple Gestations, Premature Rupture of Membranes, Post-term pregnancyGynecology: Abnormal and Dysfunctional Uterine Bleeding, Vaginal Infections, Pelvic Masses, Endometriosis,Benign and Malignant Breast Disease, Contraceptive counseling, Hormonal Replacement, Cervical Dysplasia andCancer 
--------------------------------------------------------------------------------------------------------------------------------------------Procedures:
 NEJM Videos In Clinical Medicine: http://www.nejm.org/multimedia/videosinclinicalmedicine
 --------------------------------------------------------------------------------------------------------------------------------------------Pelvic Exam Tips From Gynecologists
 Sexual abuse during childhood is not uncommon and a pelvic exam can bring back memories and emotions, even if the patient has forgotten the abuse. The patient may be sensitive to the subtle nuances in physician’s words or facialexpression. The demeanor of the physician is extremely important in establishing and maintaining rapport.Always obtain consent prior to a pelvic exam. Always have a second medical professional present for the exam andone medical provider should be female.If the patient is getting a pelvic exam for a non-routine visit (e.g. Pap screen), always explain why it is needed.A good starter phrase prior to the pelvic exam is “If anything I do is uncomfortable, please let me know.”Use neutral language during the exam. Say the exam looked “healthy” or “normal.” Do not say works like good or great as these could be construed as references to the patient’s genitalia.Connotation matters. Say “let your legs gently fall wide apart,” not “spread your legs.”Show you care about the patient’s comfort during the exam. Place the warmed speculum against the patient’s legand ask if the temperature is good.Telling a patient to “relax” is patronizing and basically impossible during a pelvic exam. A better method to helprelax the pubococcygeal muscles is ask the patient to push their bottom into the table like they are sinking into sand.
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How To Succeed – First Aid For The Obstetrics & Gynecology Clerkship (Stead, Stead, & Kaufman)
 Be On Time
: Most OB/GYN teams begin rounding between 6am and 7am. Give yourself at least 10 minutes per  patient for pre-rounding to learn about events that occurred overnight or lab/imaging results.
 Dress In A Professional Manner 
: Regardless of what the attending wears. A short white coat should be worn over your professional dress clothes unless it is discouraged (e.g. pediatrics).
 Act In A Pleasant Manner 
: The medical rotation is often difficult, stressful, and tiring. Smooth out your experience by being nice to be around. Smile a lot and learn everyone’s name. Don’t be afraid to ask how your resident’sweekend was. If you do not understand or disagree with a treatment plan or diagnosis, do not “challenge.” Instead,say “I’m sorry, I don’t quite understand, could you please explain...” Show kindness and compassion toward your  patients. Never participate in callous talk about patients.
Take Responsibility
: Know everything there is to know about your patients: their history, test results, details abouttheir medical problem, and prognosis. Keep your intern or resident informed of new developments that they mightnot be aware of, and ask them for any updates you might not be aware of. Assist the team in developing a plan;speak to radiology, consultants, and family. Never give bad news to patients or family members without theassistance of your supervising resident or attending.
 Respect Patient’s Rights
:
1) All patients have the right to have their personal medical information kept private. This means do not discuss the patient’s information with family members without that patient’s consent, and do not discuss any patient inhallways, elevators, or cafeterias.2) All patients have the right to refuse treatment. This means they can refuse treatment by a specific individual (you,the medical student) or of a specific type (no nasogastric tube). Patients can even refuse life-saving treatment. Theonly exceptions to this rule are if the patient is deemed to not have the capacity to make decisions or understandsituations, in which case a health care proxy should be sought, or if the patient is suicidal or homicidal.3) All patients should be informed of the right to seek advanced directives on admission. Often, this is done by theadmissions staff, in a booklet. If your patient is chronically ill or has a life-threatening illness, address the subject of advanced directives with the assistance of your attending.
More Tips
: Volunteer, be a team player, be honest, and keep patient information handy.
 
Study Notes – Obstetrics & GynecologyJames Lamberg28Jul2010DO NOT DISTRIBUTE - 2 -
 Present In An Organized Manner 
: “This is a [age]-year-old female with a history of [major history such asabdominal surgery, pertinent OB/GYN history] who presented on [date] with [major symptoms, such as pelvic pain,fever], and was found to have [working diagnosis]. [Tests done] showed [results]. Yesterday the patient [stateimportant changes, new plan, new tests, new medications]. This morning the patient feels [state the patient’s words],and the physical exam is significant for [state major findings]. Plan is [state plan].”
Terminology
: G (gravidity) 3 = total number of pregnancies, including normal and abnormal intrauterine pregnancies, abortions, ectopic pregnancies, and hydatidiform moles (Remember, if patient was pregnant with twins,G = 1.) P (parity) 3 = number of deliveries > 500 grams or 
24 weeks’ gestation, stillborn (dead) or alive(Remember, if patient was pregnant with twins, P = 1.)Ab (abortion) 0 = number of pregnancies that terminate < 24th gestational week or in which the fetus weighs < 500grams LC (living children) 3 = number of successful pregnancy outcomes (Remember, if patient was pregnant withtwins, LC = 2.)
TPAL
: Or use the “TPAL” system if it is used at your medical school:T = number of term deliveries (3) P = number of preterm deliveries (0) A = number of abortions (0) L = number of living children (3)
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Top 100 Secrets – Ob/Gyn Secrets (3rd, Bader)
1) The ulcer of syphilis is usually single and painless, while the ulcer of herpes is more often multiple and painful.2) Trichomoniasis and candidiasis are diagnosed by visualizing the organisms on microscopy of vaginal discharge; bacterial vaginosis is diagnosed by the "whiff test" and the appearance of "clue cells".3) PID is often a polymicrobial infection but generally begins with infection with N. gonorrhoeae or C. trachomatis.4) Midcycle surge of luteinizing hormone (LH) predicts impending ovulation.5) In females, the order of puberty is thelarche, pubarche, maximum growth velocity, and menarche.6) The three most common causes of primary amenorrhea are gonadal dysgenesis, müllerian agenesis, and androgeninsensitivity.7) The most common cause of secondary amenorrhea is pregnancy.8) The two syndromes that are characterized by breast development and the absence of a uterus, androgeninsensitivity and müllerian agenesis, can be differentiated by a karyotype.9) Premenstrual syndrome (PMS) is defined as the emotional and physical symptoms that occur at the same time prior to the menstrual cycle each month.10) Fibroids are estrogen-sensitive, fibromuscular benign tumors that are thought to originate from a monoclonalcell line.11) There are no diagnostic criteria for polycystic ovarian syndrome (PCOS), but common findings includeincreased LH:FSH ratio, decreased fasting glucose:insulin ratio, polycystic ovaries on ultrasound, hirsutism, andobesity.12) Endometriosis, or endometrial tissue outside the uterus, causes pelvic pain, dyspareunia, and infertility.13) Adenomyosis, or endometrial tissue in the myometrium, causes menorrhagia and dysmenorrhea.14) All pelvic pain is not gynecologic in origin.15) Ovarian failure is normal at menopause (average 51 years old) and premature at > 40 years; it requires work-upin women < 30 years old.16) Risks of ovulation induction include multiple gestation and ovarian hyperstimulation.17) Initial evaluation of an infertile couple should include basal body temperature chart to assess ovulation, semenanalysis, hysterosalpingogram to check tubal patency, then postcoital test to evaluate cervical mucus.18) In vitro fertilization (IVF), a procedure used to overcome tubal or male factor infertility, requires ovarianhyperstimulation with injectable gonadotropins, egg retrieval, fertilization, and embryo transfer.19) Stress incontinence is loss of urine due to increased intra-abdominal pressure, and urge incontinence is due todetrusor instability.20) Stress incontinence can be due to urethral hypermobility or, less commonly, intrinsic sphincter deficiency.21) 15-20% of clinically recognized pregnancies end in miscarriage, but this risk is decreased to 6-8% onceembryonic cardiac activity is seen.22) The most common type of chromosomal abnormality in miscarriages is autosomal trisomies, but the single mostcommon karyotype is monosomy X.23) Legalization of abortion has significantly reduced the number of women hospitalized with complications of abortions.24) Patients with ectopic pregnancies usually present with abdominal pain and abnormal vaginal bleeding.25) In a normal pregnancy, beta-hCG levels approximately double every 48 hours.
 
Study Notes – Obstetrics & GynecologyJames Lamberg28Jul2010DO NOT DISTRIBUTE - 3 -26) Combination oral contraceptives (OCPs) work primarily by inhibiting ovulation through suppression of LH andFSH.27) OCPs decrease the risk of ovarian and endometrial cancers.28) The phases of the sexual response cycle are excitement, plateau, orgasm, and resolution.29) Vaginismus is often associated with a history of sexual abuse or trauma.30) Symptoms of menopause include irregular then absent menses, hot flashes, and vaginal atrophy or dryness.31) Vulvar cancer is predominantly squamous cell and spreads via lymphatics to superficial inguinal nodes.32) Paget's disease of the vulva may be associated with underlying adenocarcinoma; therefore, local excision isrecommended.33) Human papillomavirus (HPV) can trigger genital dysplasia and is linked to invasive cervical cancers.34) The incidence of cervical cancer is decreasing secondary to regular screening with Pap smears.35) Cervical cancer is staged clinically with exam under anesthesia, cystoscopy, and proctoscopy.36) Important risk factors for endometrial cancer include obesity, anovulation, and tamoxifen use.37) The most common presenting symptom of endometrial cancer is abnormal uterine bleeding, especially postmenopausal bleeding.38) Sex cord and germ cell tumors are usually diagnosed early and are highly curable, while epithelial ovariancancer presents late in the disease.39) Meigs syndrome mimics advanced-stage ovarian cancer but actually involves benign ovarian fibroma associatedwith ascites and pleural effusion.40) The highest risk for serious injury or death is when or after an abused woman leaves her abuser.41) The incidence of domestic violence increases during pregnancy and postpartum.42) A woman with a history of a child with a neural tube defect needs 4 mg of folic acid prenatally, but thosewithout such a history need only 400 mcg.43) Advanced maternal age is associated with increased chromosomal abnormalities, increased first-trimester losses,and increased risk of most obstetric complications.44) An increase in plasma volume that is greater than the increase in red blood cell mass causes the dilutional physiologic anemia of pregnancy.45) Pregnancy is a hypercoagulable state due to increased clotting factors and venous stasis.46) To decrease group B streptococcal neonatal sepsis, the CDC recommends maternal screening for the bacteria viavaginal and rectal cultures in the late third trimester and prophylaxis with antibiotics in labor for those who test positive.47) The nonfasting 1-hour, 50-gm glucose tolerance test is used to screen for gestational diabetes, and the fasting 3-hour, 100-gm glucose tolerance test confirms the diagnosis.48) The recommended weight gain in pregnancy is 25-35 pounds for normal weight women.49) Nausea and vomiting of pregnancy typically begin around the fourth to the seventh week and end by the twelfthweek.50) There is no method proven to prevent preeclampsia, and the only cure is delivery.51) Magnesium sulfate is given to preeclamptic women during labor and for 24 hours after delivery to preventseizures.52) If a woman has a history of gestational diabetes, her lifetime risk of developing type 2 diabetes is 36%.53) To decrease the malformation risk in patients with insulin-dependent diabetes mellitus (IDDM), good glycemiccontrol should be achieved prior to conception.54) Circulating T4 and T3 increase in pregnancy secondary to increased thyroid-binding globulin, but free levels areunchanged.55) The risk of congenital anomalies is 2-3 times higher than baseline in women on anticonvulsants, but the risk isincreased above baseline even in women with epilepsy not on medications.56) Cardiac output increases in pregnancy, first by increased stroke volume, then by increased heart rate.57) Women with cardiac valvular disease and ventricular septal defects should receive subacute bacterialendocarditis prophylaxis at the time of vaginal delivery.58) Treatment of asthma in pregnancy is essentially the same as in nonpregnant women.59) Pulmonary embolism is the leading cause of maternal mortality in the U.S.60) During pregnancy, increased renal plasma flow and increased glomerular filtration rate lead to decreased serumBUN and creatinine.61) Pregnancy increases the risk of pyelonephritis due to anatomic changes, changes in urine content, and increased progesterone affecting ureteral motility.62) Maternal parvovirus infection can lead to fetal anemia, hydrops, and even IUFD.

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