OB/GYN Student Study Guide

Abbreviation and Definitions
LMP: last menstrual period
PMP: previous menstrual period
EDC: estimated date of confinement
GP: gravida !ara: Gravida is how many pregnancies; Para is the number of
times the uterus is emptied
TPAL: (“Tennessee Power and Light!: Term ("! (the number
of term pregnancies # twins count as $ pregnancy%! Preterm
("! Abortions (elective or spontaneous "! Living " (all children
counted here!
G$P$&&' ( Twins
C"C: cold )nife coni*ation LEEP: loop electrocautery e+cision procedure
B#L: bilateral tubal ligation D$C: dilation and currettage POC: products of conception
%ystero: uterus #&%: transvaginal hysterectomy #A%: transabdominal hysterectomy
LA&%: laparoscopic assisted vaginal hysterectomy #L%: total laparoscopic hysterectomy
BSO: bilateral salpingoopherectomy
O'igo: few tra()e'o: cervi+
%y!er: too much (u'!o: vagina
%y!o: not enough e(to*y: removal of
Meno: menses ooto*y: incision
Metr: uterus osto*y: ma)ing a new opening
+r)ea: flow (entesis: needle into something
+r)agia: e+cess flow !o'y*enorr)ea: cycle every '& days
P+OM: premature rupture of membranes PP+OM: preterm premature rupture of membranes
S&D: spontaneous vaginal delivery L#CS: low transverse cesarean section
+ L#CS: repeat LT,- ,A&D: forceps assisted vaginal delivery &BAC: vaginal birth after c.s
&A&D: vacuum assisted vaginal delivery &M-: viable male infant &,-: viable female infant
SAB: spontaneous abortion (miscarriage! EAB: elective abortion
-.,D: /ntrauterine fetal demise
ASC.S: atypical s0uamous cells of undetermined significance
LGS-L: low grade s0uamous intra epithelial lesion
%GS-L: high grade s0uamous intra epithelial lesion
1
st
Trimester: w& # w$' gestational age
2
nd
Trimester: w$' # '1
3
rd
Trimester: w'1 # 2&
Previable: less than '& wee)s; if delivered considered Abortion3 not -45
Preterm: '2678 w
Term: 78 # 2' w
Embryo: fertili*ation to 1 wee)s
Fetus: 1 wee)s to birth
Infant: delivery to $ year
Post Dates: 9 2$62' wee)s
Pregnan(y and Prenata' Care
Diagnosis: home :PT: highly sensitive at the time of missed cycle (positive at 16; d!; b<,G
rises to $&&3&&& by $& wee)s and levels off at$&3&&& at term; can get gestational sac as early as
= wee)s> At that point your b<,G should be $=&& to '&&&>
Dis(ri*inatory /one: This means that when ?<,G is $'&&6$=&&3 evidence of a pregnancy
should be seen on transvaginal ultrasound> @hen the ?<,G is A&&&3 you can see evidence on a
transabdominal ultrasound>
,%#: seen at BA wee)s on :-; 5oppler C<T at $' w
Gestationa' Age: days and wee)s from LDP
Dating Age (not used e+cept on tests%!: wee)s and days from fertil*ation; GA ' wee)s greater
than 5A
Naeg'e0s +u'e: Cor E5,: LDP # 7 months F 8 days F $ year
.'trasound: can be $ wee) off in the first trimester3 ' wee)s off in the second trimester3 7 wee)s
in the third trimester soG if your US differs from the EDC by LP more than this! a""e#t the US
datin$ over the LP datin$> /n the first half of the first trimester3 use the ,rown Hump Length
(,HL! which is within 7 # = days of accuracy>
Do!!'er: can get C<T (fetal heart tones! at $' wee)s
1ui(2ening: at $A # '& wee)s (mom feels the baby move!
Signs and S3 of Pregnan(y:
a> ,hadwic)Is -ign6blue hue of cervi+
b> GoodellIs -ign # softening and cyanosis of c+ at 2 wee)s
c> LaddinIs -ign # softening of uterus after A wee)s
d> ?reast swelling and tenderness
e> Linea nigra
f> Palmar erythema
g> Telangiectasias
h> Jausea
i> Amenorrhea3 obviously
K> Luic)ening
Nor*a' C)anges in Pregnan(y:
$> ,4 #
a> ,M inc by 7&6=&N O ma+ '& # 2& wee)s
b> -4H dec secondary to inc> progesterone and therefore smooth muscle rela+ation
c> ?P dec: systolic down = # $&. diastolic down $& # $= until '2 wee)s then slowly
returns>
'> Pulmonary:
a> T4 inc 7& # 2&N
b> Dinute 4ent inc 7& # 2&N
c> TL, dec =N secondary to elevation of diaphragm
d> PA M' and pa M' inc; dec pA ,M' and pa ,M'
7> G/:
a> Jausea and vomiting in 8&N 6 inc> estrogen3 progesterone and <,G; resolves by
$2 # $A w
b> Heflu+ # dec> GE sphincter tone
c> 5ec lower intestinal motility3 inc water reabsorption and therefore constipation
2> Henal
a> Pidneys increase in si*e
b> :reters dilate # increased ris) of pyelonephritis
c> GCH inc =&N 6 ?:J3 ,rt dec '=N
=> <eme
a> Plasma volume inc by =&N3 H?, vol inc '& # 7&N 6 drop in <ct
b> @?, still nl at $& # '& in labor
c> <ypercoaguability
d> /nc> fibrinogen3 inc factors 8 # $&3 dec $$ # $7
e> -light dec in plt3 slight dec in PT.PTT
A> Endocrine
a> /nc estrogen from palcenta; dec from ovaries # low estrogen levels assn with
fetal death and anencephaly
b> Progesterone is produced by corpus luteum then the palcenta
c> <,G # doubles roughly every 21 hours; pea)s at $& # $' wee)s; the alpha
subunit loo)s li)e L<3 C-< and T-< but the beta subunit differs
d> /nc in thyroid binding globulins
8> Dusculos)eletal.5erm # -pider angiomata3 melasma3 linea nigra3 palmar erythema
a> ,hange in the center of gravity # low bac) pain>
1> Jutrition # '&&& # '=&& cal.day
• need to increase #rotein! "al"ium and iron6 an iron su!!'e*ent is
needed in the second trimester> 7& mg of elemental iron is
recommended
i> folate is necessary early on to prevent nueral tube defect (spina bifida! #
2&& mcg per day is recommended in women without sei*ure meds or
previous infant with neural tube defect (2g are recommended then!
ii> '& # 7& lb weight gain is MP3 obese women do not have to gain weight>
Prenata' Care
,irst #ri*ester: ,?,3 ?lood Type and -creen3 HPH3 Hubella3 <ep ? s Ag3 </43 :A.,+3 G,3 ,hl3
PP53 Pap -mear (without cytobrush!
 Appt 0 mo>
 5oppler C<T O $& # $' w
 MP 5rugs: Tylenol3 ?enadryl3 Phenergan
 Houtine labs 0 visit: C<T3 Cundus height3 :rine dip (prt3 bld3 glucose3 etc!3 weight3 ?P
Se(ond #ri*ester: D-ACP.Triple -creen O $= # $1 w)s3 MI-ullivan O '2 # '1 wee)s
 Luic)ening at $8 # $; wee)
 Glucose Tolerance Test 4alues: %Sullivan& =& g glucose  normal: under $2&; if over
then perform $&& g $lu"ose toleran"e test
 Casting $&=
 $ hour $;&
 ' hours $A=
 7 hours $2=
 Hhogam O '1 wee)s
#)ird #ri*ester: HPH3 ,?,3 Group ? -trep 7=678 wee)s (if not scheduled for repeat cesarean!3
cervical e+am every wee) after 78 wee)s or the onset of contractions
 Labor #re"autions& “Go to LQ5 if you have contractions every = minutes3 if you feel a
sudden gush of fluid3 if you donIt feel the baby move for $' hours3 or if you have bleeding
li)e a period> /tIs normal to have mucus or a pin) discharge in the wee)s preceding your
labor>
+outine Prob'e*s of Pregnan(y:
?ac) Pain GEH5 ,onstipation
<emorrhoids 4aricose 4eins ?ra+ton <ic)s
Pica (cravings! 5ehydration Hound ligament pain (inguinal pain3 worse on
Edema Cre0uency wal)ingTR: Tylenol3 heating pad3
Daternity belt!
MSA,P: produced by placenta: goes through amniotic fluid  mom
 /nc D-ACP: neural tube defects3omphalocele3gastroschisis3 mult gest3 fetal death3
in(orre(t dates
 5ec D-ACP: 5ownIs3 certain trisomies
 TH/PLE -,HEEJ: D-ACP3 Estriol3 ?<,G6 ris) for defects is calculated> /f it comes bac)
abnormal3 ma'e sure datin$ is a""urate3 then counsel patient and consider
amniocentesis>
#ri!'e S(reen #ri 45 #ri 56
MSA,P dec dec
Estrio' /J, dec
B%CG /J, dec
 Amniocentesis can be done to get babyIs )aryotype if abn :-3 aberrant D-ACP3 Adv
Daternal Age or Camily history of abnormalities
 ,an do a ,horionic 4illi -ampling O ; # $$ wee)s if you need a )aryotype sooner3 have
inc> ris) of PPHMD3 previable delivery3 fetal inKury however>
P.BS: percutaneous umbilical blood sampling: gets fetal blood to test for degree of fetal
anemia.hydops in Hh disease3 etc>
,eta' Lung Maturity:
 Lecithin.-phingomyelin Hatio: over '>& indicates fetal lung maturity
 “CLD: Clouresence Polari*ation: 9==mg.g is mature; good for use in diabetics
 Phosphatidyl glycerol: comes bac) pos or neg: best for diabetics because is last test to
turn positive; hyperglycemia delays lung maturity
Clinic Survival Guide Copy and put in your pocket!
Clinic note:
21 yo G2P1001 at 28 2/7 by 8 week ultrasound (always include dating criteria) coplaining o! inguinal
pain on walking" #enies contractions$ %aginal bleeding$ rupture o! ebranes$ and &as !etal
o%eent (t&e cardinal 'uestions o! obstetrics)"
(P 110/)8 *rine+ trace protein (pregnant woen usually &a%e trace protein) neg glucose
,undal -eig&t(,-)+ (easured !ro t&e pubic syp&ysis to !undus. correlates wit&in 1.2 c unless obese) 2/c
,etal -eart 0ones (,-0)+ 110s (count t&e out on your watc& in t&e beginning2 noral 120s.1)0s)
34treities+ no cal! tenderness
(any results o! recent ultrasounds$ lab work &ere)
5/P+ 1" 6*P at 28 2/7+ si7e appropriate !or dates
2" 8ound 9igaent Pain+ recoended aternity belt
:" 8- ;eg+ 8&oga :00 cg 6< today
:" Continue P;=/ ,e$ discussed preter labor precautions
1" > ?ulli%an today
6"<" ?tudent$ 9:
Coplaints+
 #isc&arge  do cultures$ wet prep (look !or tric&)2 ucus noral at ter
 0&e baby doesn@t o%e at ties  babies go t&roug& noral sleep cycles" 5s long as it
o%es e%ery couple o! &ours$ t&at@s !ine" Aick counts. lie on side and count t&e aount o!
kicks in one &our a!ter dinner. s&ould be o%er 10"
E(to!i( Pregnan(y
 Dost common place # ampulla of the fallopian tubes; also located in ovary3 abd wall3
cervi+3 bowel
 +is2 fa(tors: /nf+ of tube3 P/53 /:5 use3 previous tubal surgery3 assited reproduction
 Mccur in $.$&& pregnancies
 SS: episodic lower abd pain
o Abnormal bleeding: due to inade0uate progesterone support
o <,G decreased: normally3 <,G doubles every other day; in ectopics it doesnIt
o :nilateral tenderness
o F.6 mass
o ,ullenIs sign (periumbical <ematoma!
o :.- finding6 comple+ adene+al mass3 can see sac or fetus3 even
 #7: Dethotre+ate =& mg.m' if () "m! unru#tured: follow serial <,Gs 2 and 8 days later>
Sou want the value to drop $=N between days 2 and 8> /f it doesnIt3 you give another
dose of methotre+ate> If the mass is * ) "m then salpingostomy or salpingectomy (if
patient is stable3 can do this laparoscopically; if not needs emergent laparotomy!
 Arias8Ste''a +3n: assn with ectopic pregnancy; endometrial change that loo)s li)e clear
cell carcinoma (but is not cancerous!
S!ontaneous Abortions 9 :4; <ee2s=
 Mccur in $= # '=N of pregnancies
 A&N assoc with abn chromosomes ("$ cause: Trisomy $A3 "': Donosomy R!
 +, if re(urrent: inf+3 maternal anatomic defects3 Antiphospholipid -d; endocrine
problems (of mom!3 previous miscarriage
 LABS to do: b<,G3 ,?,3 type and screen3 :-; give Hhogam if Hh 6
 5efinitions:
o #)reatened AB # intrauterine pregnancy with bleeding; ('osed (ervi3  needs
initial obstetric visit
o Missed AB # Cetal death without passage of products of conception; no C<T by
1 wee)s
o -nevitab'e AB # dilated cervi+3 proceeds to complete or incomplete
o -n(o*!'ete AB # products not all out  do a 5Q,
o Co*!'ete AB # Products all out; need to follow ?<,G until & to ma)e sure it
was not a hydatidiform mole or choriocarcinoma
 SS: bleeding3 crampy abdominal pain (always as) if clot or whitish tissue was passed!
 Abortion > ? @ 6 <ee2: $> Trisomies '> TurnerIs -d (2=R!
 %abitua' Ab: 7 AbIs in a row
o ,auses: balanced translocation of parents3 autoimmune d*3 abn uterus3 etc>
o @:: )aryotype for balanced trans3 antiphospholipid ab3 hysterosalpinography for
abn uterus (septate uterus most common!
 -n(o*!etent Cervi3 Sd: AbIs between $7 # '' wee)s because cervi+ canIt hold PM, in:
see painless dilation and effacement in '
nd
trimester; inf+ is common b.c of
trauma.vaginal flora
#7: Dc5onaldIs ,erclage: a pursestring nonabsorpable suture around
cervi+: remove at term; also could manage e+pectantly; ?E5HE-T # give steroids and
Ab+ to dec inf+ and inc fetal lung maturity and tocoly*e contractions; ?oth Dc5onald and
-hirod)ar are near the internal os # -hirod)ar stitch Kust tunnels under the cervical
epithelium>
 Causes of 4
nd
#ri*ester Abs: inf+3 mat anat defects3 cervical defects3 systemic d*3
fetoto+ic agents3 trauma (chromosomes occur in second trimester3 but not as fre0uently
as first trimester!
C)ro*oso*e Stuff
 Trisomies: $7 Edwards3 $1 Patou3 '$ 5ownIs
 Autosomal 5ominant 5*: Jeurofibromatosis3 von @illebrandIs3 Achondroplasia3
Msteogenesis imperfecta
 R Lin)ed 5*: Duscular 5ystrophy3 GAP5 5ef3 hemophilia
 Hecessive 5*: $' M< Adrenal hyperplasia
 Dc,une Albright: polyostotic fibrous dysplasia: degeneration of long bones3 se+ual
precocity3 cafT au lait spots (t+ precocious puberty with medro+yprogesterone acetate!
Statisti(a' Stuff
 Daternal Dortality ( mat death.$&&3&&& live births
 Certility rate ( " live births.$&&& females $= # 22
 ?irth rate ( " live births . $&&& people
Ante!artu* ,eta' Survei''an(e
 NS# ( Jon -tress Test: to be “reactive need ' a((e'erations of 5A beats !er *inute
for 5A se(onds in 4; *inute stri!; if nonreactive3 baby can be sleeping # give mom
Kuice # do a ?PP (thin) about sedatives3 narcotics3 ,J-.,4 abnormalities!
 BPP ( biophysical profile; on :.- 1 pts good. 2 pts bad
Give ' points Give & points
J-T Heactive U ' accels
AC/ (amniotic Cluid /nde+! one ' by ' cm poc)et no poc)et seen
Cetal ?reathing Dovements Last over 7& seconds U 7& seconds
Cetal E+tremity Dovements 7 or more episodes :nder 7 episodes
Cetal Tone E+tension to fle+ion; fle+ at rest E+tended at rest
 Modified BPP ( J-T and AC/
 Contra(tion stress test 9CS#!: nipple stimulation or o+ytocin # shows 7 uterine
contactions in $& minutes to be good; negative ( no late decelerations
 %OB #O +EAD #%E S#+-P:
o Heassuring things # normal behavior3 beat to beat variation3 reactive strip
(above!
o Early decels # they begin and end with the contraction # a sign of head
compression # MP
o 4ariable decels # are more Kagged and loo) li)e a 4 # a sign of cord compression
# we may start amnioinfusion
o Late decels # begin at pea) of contraction and end after contaction is finished # a
sign of uteroplacental insufficiency # are bad> (nonreassuring!
 ,SE ( fetal scalp electrode6 placed usually with /:P, when a more accurate recording of
heart tones is needed; do not use in moms with </4
 -.PC ( /ntra :terine Pressure ,atheter # placed in uterus to monitor contractions; a good
baseline is $&6$= mm <g; ,t+ in labor inc> '& # 7& mm<g or even to 2& # A&; can
amnioinfuse through the /:P, with normal saline6 +ou "annot tell ho, stron$ a
"ontra"tion is ,ith the to"ometer- +ou need an IUPC to "ount onte.ideoUnits-Mver '&&
D4:s is considered ade0uate>
 ,eta' S(a'! !%; ta)e blood from scalp for nonreassuring factors3 fetal hypo+ia (not really
done anymore!
P< over 8>'= is reassuring 8>' # 8>'= indeterminate U8>' bad
Labor
DA#-NG
 Denstrual <istory: 2& wee)s from LDP (JaegleIs rule: LDP F 8 days # 7 months!
 :terine -i*e:
o $& @ee)s grapefruit si*e
o '& wee)s is at umbilicus
o '& # 77 wee)s matched dates F6 ' cm of Cundal <eight
o may not match at term due to descent
 :ltrasound: is most accurate at 1 # $' wee)s
 5ating ,riteria for delivery: determines whether lungs are considered mature for delivery
$> C<T documented 7& wee)s by 5oppler>
'> 7A wee)s since :PT positive>
7> :- of ,HL at A6$$ wee)s ma)es gestational
age 97; wee)s>
2> :- of under '& wee)s supports gestational
age 97; wee)s>
S#AGES O, LABO+
 ,irst: beginning of contractions to complete cervical dilation
o Latent # to appro+> 2 cm (or acceleration in dilation!
o Active # to $& cm complete; prolonged if slower than 5C4 (*/)r nu''/5CA (*/)
*u'ti!; if prolonged3 do amniotomy3 start pitocin3 place /:P, to evaluate
contraction strength
o ,ai'ure to !rogress # no change despite ' hours of ade0uate labor (D4: 9'&&!
 Se(ond: complete dilation to the delivery of baby
o Prolonged if 4 )ours *u'ti!/ D )ours nu''i! 9with epidural! or ' hours nullip.$
hour multip (no epid!
 #)ird: delivery of baby to delivery of placenta
o ,an ta)e up to 7& mins
o -igns include increase in cord length3 gush of blood3 uterine fundal rebound
 ,ourt): one hour post delivery
D P0S O, LABO+
$> Po<er: nl contractions felt best at fundus; last 2=6=& seconds; 7 in $& minutes
'> Passenger:
a> Presentation # what is at the cervi+ (head (verte+!3 breech!
b> Position # MA3 MP3 LMT3 HMT
c> Attitude # relationship of baby to itself
d> Lie # long a+is of baby to long a+is of mom
e> Engagement # biparietal diameter has entered the pelvic inlet
f> -tation # presenting partIs relationship to ischial spine (673 6'3 6$3 &3 $3 '3 7!
7> Pe'vi*etry:
a> /nlet: 5iagonal ,onKugate # symphysis to sacral promontory ( $$>= cm
Mbstetrical ,onKugate # shortest diameter ( $& cm
b> Didplane: spines felt as prominent or dull
c> Mutelt: ?ituberous 5iameter ( 1>= cm
-ubpubic Angle less than 2& degrees
,O+CEPS
 Mutlet forceps: re0uirements #
 visible scalp
 -)ull on pelvic floor
 Mcciput Anterior or Posterior
 Cetal head on perineum : can see without separating labia
 Ade0uate anesthesia; bladder drained
 Da+imum 2= degrees of rotation
 Low forceps:
 station ' but s)ull not on pelvic floor
 Didforceps: station higher than ' with engaged head (not done!
&ACC..M E7#+AC#-ON: can cause cephalophematoma and lacerations
 -ame re0uirements for outlet forceps
-ND.C#-ON:
 -ndi(ations: PreEclampsia at term3 PHMD3 ,horioamnionitis3 fetal Keopardy.demise3
92'w3 /:GH
 Bis)o! S(oring Syste*: if induction is favorable: 91 vaginal delivery without induction
will happen same as if with induction: U 2 usually fail induction: U = # =&N fail induction
-core ,m Effacement -tation ,onsistency Position of c+
& & &67&N 67 Cirm Post
$ $6' 7&6=&N 6' Ded Did
' 762 A&68&N 6$3& -oft Ant
7 26= 91&N F$3 F'
 Prostag'andins: dilate cervi+ and inc contractions: Prepidil3 ,ervidil3 ,ytotec:
contraindicated in prior ,-3 nonreassuring fetal monitoring
 La*inaria: an osmotic dilator3 is actually seaweed%
 A*nioto*y: speeds labor; beware of prolapsed cord%
 O3yto(in: $& : in $&&& ml /4 piggybac) on pump O ' m :.min; if over 2& m:.min are
used watch for -/A5<
 Augmentation of labor needed in inade0uate ct+3 prolonged phases
DEL-&E+Y
 ,rowning 6 HitgenIs maneuver (hand pressure on perineum to fle+ head! <ead out:3
chec) for nuchal cord (cord around nec)! # delivery anterior shoulder gently by pulling
straight down6 suction nares and mouth with bulb # deliver posterior shoulder # clamp
cord with ' Pellys3 cut with scissors3 hand off baby # get cord blood# gentle traction on
cord with suprapubic pressure3 massage momIs uterus # retract placenta out and inspect
it # inspect mom for tears3 visuali*e complete cervi+
 Episiotomy repair ($ # ' degree midline! ' # & ,hromic or 4icryl loc)ing suture superiorly
to repair vaginal mucousa # interrupted chromics to repair deep fascia if needed # simple
running to repair mid fascia # sub L stitch inferiorly and superficially
 A t)ird degree tear involves the rectal sphincter; a fourt) degree tear involves rectal
mucousa
 Didline episiotomy: can e+tend3 but has less dyspareunia; Dediolateral episiotomy is
done at = or 8 oIcloc)3 but has more pain and inf+ but less chance of e+tension (consider
if shoulder dystocia!
 S)oud'er Dysto(ia
HC: macrosomia3 5D3 obese3 post dates3 prolonged second stage>
,ompl: fracture3 brachial ple+us inKury3 hypo+ia3 death
Treatment:
$> -uprapubic Pressure (not fundal pressure%!
'> DcHobertIs # mom fle+es hips # )nees to chin level
7> GEJTLE traction
2> @oodIs ,or)screw # pressure behind post shoulder to dislodge the ant shoulder
=> Hubin maneuver # pressure on accessible shoulder to push it to ant chest of
fetus to decrease biacromial diameter
A> Cracture clavicle away from baby
8> try to deliver posterior arm
CA+D-NAL MO&EMEN#S
 Engagement # fetal head enters pelvis
 Cle+ion # smallest diameter to pelvis
 5escent # verte+ to pelvis
 /nternal Hotate # sag suture is parallel to AP
 E+tend at pubic symphysis
 E+ternally rotate after head delivery
-ND-CA#-ONS ,O+ C8SEC#-ON
 Cailure to progress (PIs of labor!
 ?reech presentation with labor
 -houlder presentation
 Placenta Previa
 Placental Abruption
 Cetal distress: = minutes of decal U;& bpm; repetitive late decals unresponsive to
resusitation
 ,ord Prolapse
 Prolonged second stage of labor
 Cailed forceps
 Active herpes
 Prior classical ,.- (has to do with incision on uterus not s)in%!
 ' prior low transverse c.s (4?A,s are controversial!
.'trasound
5oppler 4elocimetry: systolic.diastolic ratio in the umbilical cord
 /nc -.5 ratio: pre6eclampsia3 /:GH3 nicotine3 maternal tobacco
 /f end diastolic flow absent or reversed3 delivery is indicated
 4elocimetry is done in cases of suspected /:GH
The first ultrasound is the only one that can change dates> Accept :.- date if over LDP date byG
 2d # $ w: first trimester
 'w: second trimester
 7 w: third trimester
5ating is done by a biparietal diameter3 head circumference3 femur length and abdominal
circumference>
Anest)esia
E!idura' anest)esia: lengthens second stage # may need o+ytocin
 /nKected into L7.L2 interspace: use the techni0ue of least resistance (the epidural space
has a negative atmospheric pressure so the syringe you place over the needle will
suddenly lose its resistance as you advance it into the epidural space3 inKect test dose!
 ,an cause hypotension after dosage because the autonomic nervous system is bloc)ed
and all blood pools in e+tremities; can see late decals3 but usually resolve with hydration
and blood pressure increase>
Para(ervi(a' b'o(2: not really done because can inKect into fetus easily and cause fetal
bradycardia
S!inal: one time dose3 shorter duration of action3 used in repeat c.s
Pudenda' B'o(2: ,an be done with vaginal delivery3 inKect analgesic into post6ischial spine and
sacrospinous ligament (ta)es = # $& mins to set up: good for forceps delivery without epidural!
,eta' Co*!'i(ations of Pregnan(y
SMALL ,O+ GES#A#-ONAL AGE
 U $&N percentile for growth
 can be symmetric or asymmetric
 has higher rates of mort.morbidity
 HC: 5ecreased growth potential
o ,ongenital abn: Tri $73 $13 '$3 Turners
o ,D43 Hubella
o Teratogens3 smo)ing3 EtM<
-.G+:
 ,auses: <tn3 5D3 renal d*3 malnutrition3 plac previa3 abruption3 ,D43 To+o3 Hubella and
mult gest
 -ymmetric: insult was early in gestation ie> 4iral
 Asymmetric: late onset (ie> Tobacco!; femur length is usually spared
 5oppler velocimetry with end diastolic flow reversed or absent or nonreassuring fetal
heart tracing necessitates delivery>
MAC+OSOM-A: 9 ;&N percentile: 9 2=&&g
 <igher ris) of shoulder dystocia and birth trauma (brachial ple+us inKuries!3 low APGAH3
hypoglycemia3 polycythemia3 hypocalcemia3 Kaundice
 E#-O: 5D3 obesity3 post term3 multiparity3 inc> age
 ,.: u.s 0 ' wee)s to assess si*e; however :- is not that accurate in diagnosis
 #7: tight control of diabetes; wt loss before conception; induce3 prepare for dystocia;
consider c.s if over =&&&g
OL-GO%YD+AMN-OS:
 Amniotic Cluid inde+: divide momIs belly into 2 0uadrants # measure the largest poc)et of
fluid in each U=: Mligohydramnios 9'&: Polyhydramnios
 Absence of Hange of Dotion # 2&R increase in Perinatal mortality
 Assn with abnormalities of G: (renal agenesis ( PotterIs -d3 polycystic )idney d*3
obstruction!3 and /:GH
 Cetal Pidney.lung  amniotic fluid  resorbed by placeta3 swallowed by fetus3 or lea)ed
out into vagina>
 Dost common cause: HMD (rupture of membranes!
 5+: :-
 TR: /f preterm3 hydrate if fetus stable; /f term3 deliver
POLY%YD+AMN-OS:
 AC/ 9 '& or '=; '67N of pregnancies; assn with JT defects; obst mouth3 hydrops3 mult
gest
 Donitor with serial ultrasounds> ,an do therapeutic amniocentesis>
Antenata' %e*orr)age
PLACEN#A P+E&-A: Abnormal implantation of placenta over the internal os
 Three types
$> ,omplete (completely over os!
'> Partial (little over os!
7> Darginal (barely over os!
 SS: painless vaginal bleeding # d+ by ultrasound # 5MJIT ERAD/JE @/T< SM:H
<AJ5- % Avoid speculum e+am% /f patient presents complaining of vaginal bleeding3
ma)e sure an ultrasound for placental location is performed first>
 +,: previous placental previa3 prior uterine scars3 multiparous3 adv mat age3 large
placenta
 #7: ,- if lungs mature.fetal distress.hemorrhage

 P'a(enta a((reta: superficial invasion of placenta into wall of uterus
 P'a(enta in(reta: invasion into the myometrium
 P'a(enta !er(reta: invasion into the serosa
T+ for above 7: '.7 get hysterectomy after c.s
PLACEN#AL AB+.P#-ON: premature separation of a normally implanted placenta
 SS: usually painful vaginal bleeding (uterus is contracting! . hemm between wall and
placenta
 +,: htn3 prior abruption3 trauma3 smo)ing3 drugs # cocaine3 vascular disease
 D7: inspection of placenta at delivery for clots; can see retroplacental clot on ultrasound
or a drop in serial hematocrits
 #7: deliver if fetal status nonreassuring
 Co*!'i(ations: hypovolemia3 5/,3 couvalaire uterus (brown boggy!3 PTL
.#E+-NE +.P#.+E : maKor cause of maternal death
 2&N assn with a prior uterine scar (,-3 uterine surgery!
 A&N not assn with scarring but abd trauma (D4A!3 improper o+ytocin3 forceps3 inc> fundal
pressure3 placenta percreta3 mult gest3 grand multip3 choriocarcinoma.molar pregnancy
 SS: severe abd pain3 vag bleeding3 int bleeding3 fetal distress
 #7: immediate laparotomy3 hysterectomy with cesarean
,E#AL &ESSEL +.P#.+E: occurs usually with a velamentous cord insertion between amnion
and chorion; may pass over os(vasa previa (Perinatal mortality =&N!
 SS: vag bleeding3 sinusoidal variation of <H
 +,: mult gestation ($N singleton3 $&N twins3 =&N triplets!
NON OBS#E#+-C CA.SES O, AN#EPA+#.M %EMO++%AGE
,ervictis3 polyps3 neoplasms3 vag laceration3 vag varicies3 vag neoplasms3 abd pelvic trauma3
congenital bleeding d.o
Preter* Labor
 +,: low -E-3 nonwhite3 U$1 yo3 mult gest3 h.o preterm birth3 smo)ing3 cocaine3 no PJ,
uterine malformation3 h.o ,P,3 Group ? strep3 ,hlamydia3 Gonorrhea3 ?4
 S.+&-&AL: '7 w &61N '2w $=6'&N '=w =&6A&N 'A6'1w 1=N ';w ;&N
 ALGO+-#%M:
Good 5ates
U'2w '2672w 972w
-ab Tocoysis3 -teroids E+pectant management

 CON#+A-ND-CA#-ONS #O #OCOLYS-S: acute fetal distress3 chorioamnionitis3
eclampsia.pre e3 fetal demise3 fetal maturity3 hypersensitivity to tocolytics3 heart disease3
/:GH
 BO+" .P: <QP3 chec) cervi+ visually by speculum3 wet prep3 :A3 cervical length3 fetal
fibronectin
 #OCOLY#-CS:
 MgSOE: wor)s as membrane stabili*er3 competitive inhibition of ,a;
therapeutic at 268 mE0.L
• -E: flushing3 nausea3 lethargy3 pulm edema
• To+icity: cardiac arrest (t+: calcium gluconate!3 slurred speech3
loss of patellar refle+ (O 8 6$&!3 resp problems (O$=6$8!3
flushed.warm (O;6$'!3 muscle paralysis (O$=6$8!3 hypotn
(O$&6$'!
 Nifedi!ine: calcium channel bloc)er: $& mg 0 A h; se: nausea and
flushing
 B4 agonist: ritodrine/ terbuta'ine: dec> uterine stimulation; may cause
5PA in hyperglycemia3 pulm edema3 n.v3 palpitations (avoid with h.o
cardiac disease or if vaginal bleeding! &>'= mg s0 0 '&67& min + 7 then =
mg 0 2 po
 -ndo*et)a(in/!rostag'andin synt)esis in)ibitor: =& mg po.$&& mg pr
-E: premature closure of P5A in an hour3 oligohydramnios
 ADDG
o ?etamethasone or 5e+amethasone (to increase fetal lung maturity!
o ?edrest with bathroom priviledges
o Pen G (Group ? -trep prophyla+is!
 P+E#E+M BABY +-S"S
o Low birth weight
o /ntraventricular hemorrhage
o -epsis
o Jecroti*ing enterocolitis
P+OM
Preter* P+OM U78w (usually 7'67A w! ( PPHMD
Pro'onged P+OM : rupture 9 '2 hours
 CA.SES: inf+3 hydramnios3 incompetent cervi+3 abruptio placenta3 amniocentesis
 Labor usually follows shortly
 D7: -terile speculum e+am # ferning (on slide!3 pooling (in fornices!3 nitra*ine paper
(turns blue! 6 gc3 chl3 strep ? culture :.- # loo)s for AC/ (oligohydramnios!
 MGM#: 9 7Aw  delivery
Preterm  pen G for ? strep3 e+pectant management vs> delivery for any signs
of infection or fetal compromise3 ?PPs vs> J-Ts
C)orioa*nionitis
 Def: infection of amniotic fluid
 He0uires delivery; increased ris) with inc> length of rupture of membranes
 SS: fever 9 71 c3 inc @?,3 tachycardia3 uterus tender3 foul discharge
 #7: Ampicillin and Gentamycin3 add ,lindamycin if c.s3 5EL/4EHS
 Dost common cause of neonatal sepsis
Endo*etritis
 +,: prolonged labor3 PHMD3 more c.s than vag delivery
 O+GS: polymicrobial  anerobes.aerobes li)e E ,oli.Group ? -trep.?acteroides
 SS: uterine tenderness3 foul lochia
 TR : gentamycin and clindamycin (continue until '2621 h afebrile!
Ce!)a'o!e'vi( Dis!ro!ortion
 ,ommon indication for c.s
 Types of pelvis:
 Gynecoid: $' cm widest3 sidewalls straight
 Android: $' cm diam3 sidewalls convergent
 Anthropoid: U$' cm3 sidewalls narrow
 Platypelloid: $' cm3 sidewalls wide
 Mbstetric conKugate diameter: sacral promontory to midpoint symphysis pubis: shortest
AP diameter ;>= # $$>=
Ma'!resentation
Bree(): 762N
 HC: previous breech3 uterine anomalies3 polyhydramnios3 oligohydramnios3
multigestation3 hydro.anencephaly
 Cran): fle+ed hips3 e+tended )nees (feet near head!
 ,omplete: fle+ed hips3 one or both )nees fle+ed
 /ncomplete.Cootling: one or both foot down
 5R: LeopoldIs maneuver3 vaginal e+am (feel sacrum and anus!
 TR: , -ection is the preferred management3 e+ternal version (manipulation into
verte+ position!3 trial of delivery if '&&&67=&&g and multip (has a proven pelvis!
,a(e: chin is anterior for delivery3 many anencephalics have a face presentation; d+ on e+am
Bro<: must convert to occiput for delivery
OP: usually rotate to MA (manually!
S)ou'der: transverse lie  do c section
Co*!ound: fetal e+tremity with verte+ or breech  cord prolapse; part will reduce as labor
occurs
PP %e*orr)age
5efined as 9 =&& ml blood loss following vag delivery3 9 $&&& ml blood loss following c.s
 Causes
o :terine atony coagulopathy
o Corceps uterine rupture
o Dacrosomia uterine inversion
 #7
o 4igorous fundal massage M+ytocin '& : in $&&& ml J-
o Hepair laceration Dethergine &>' mg /D (contra: htn!
o Ta)e out placental remnants PgC' # alpha (<emabate! (contra: asthma!
o ,ytotec 1&& mg rectal <ysterectomy if medical therapy fails
+) -n(o*!atibi'ity
 Dom is Hh neg (Hh is an antigen on the H?,: ,5E family! F Dad is /h #os ( baby is be
/h #os: during first pregnancy (usually at delivery but can occur with -ab3amniocentesis3
trauma3 ectopic3 etc!3 mom develops antibodies against Hh positivity (because she lac)s
the antigen! which can cross the palacenta and cause a hemolysis in the newborn which
may cause death>
 "'ei)auer Bet2e #est: assess amt of fetal blood passed into maternal circulation
 Mn first visit: blood type3 also screen for other antibodies:
o Lewis # “lives
o Pell # “)ills
o 5uffy # “dies
 +%OGAM: given as passive immuni*ation to prevent sensiti*ation: given O '1 w; chec)
baby at delivery3 if HhF  give Hhogam again to mom within 8' hours
 /f multip not sensiti*ed  t+ as above
 SensitiFed: mom has developed antibodies against baby  chec) a titer: if over $:13 do
fetal survey on :- and amniocentesis at $A # '& w to measure the M5 2=& with the
spectrophotometer (you )now3 that machine you used in general biology! reading for the
L/LES ,:H4E
@ee)s gestation
Jote: the delta M5 2=& is prognostic3 not the titeritself
Vone '.7 TR: intrauterine blood transfusion through umbilical A of H< neg blood
Vone 7  <5J
Vone ' 
ffffsdfffollfollowfollclosely
Vone $  M)ay
 E+#%+OBLAS#OS-S ,E#AL-S: heart failure3 diffuse edema3 ascites3 pericardial
effusion3 bilirubin brea)down  Kaundice3 neuroto+ic effects>
-ntrauterine ,eta' De*ise
 /:C5 assn with abruption3 congenital anomalies3 post dates3 infection3 but usually is
une+plained>
 Hetained /:C5 over 7 # 2 w leds to hypofibrinogenemia secondary to the release of
thromboplastic substance of decomposing fetus  sometimes D-C can result>
 D7: no C<T on ultrasound
 #7: delivery
 Postdates :O 2$ w: do J-T: if nonreassuring do induction
o 2'w: do ?PP and J-T ' 0 w): if nonreassuring do induction
o inc ris) of macrosomia: oligohydramnios3 Deconium aspiration3 /:C5
o 5R: by LDP3 u.s consistent with LDP in first trimester
o /nduce after 2' w
Mu'ti!'e Gestation: $.1& twins Q $.8&&& # 1&&& triplets
 Co*!'i(ations: PTL3 placenta previa3 cord prolapse3 pp hemorrhage3 pre E
 ,eta' (o*!'i(ations: preterm3 congenital abnormalities3 -GA3 malpresentation
 De'ivery: usually occurs at 7A # 78 w if twins; Triplets # 77 # 72 w
Monoygoti( #<ins: Gidenti(a'H
$> 5ichorionic diamniotic: ' chorions. ' amnions: separation before trophoblast on
embryonic dis) (splits before 8' hours!
'> Donochorionic diamniotic: has one placenta; when twins occur d> =6$& before
amnion forms
7> Donochorionic monoamniotic: one chorion and amnion; can be conKoined twins
DiFygoti( #<ins: Gfraterna'H
$> 5ichorionic diamniotic
'> /nc in Africa (Jigeria!
7> ' sperm. ' eggs
 D7: u.s3 inc <,G3 inc D-ACP
 #7: managed as high ris)
 De'ivery of #<ins:
o 2&N verte+  vaginally (only if reassuring C<T3 '=&& # 7=&& g!
o '&N vt+ . br or br . vt+ '&N  controversial3 usually c.s
o '&N br . br  cs
o Triplets  cs
Pre8E('a*!sia / E('a*!sia / C)roni( %tn
Nor*a' Mi'd Pre E Severe Pre E
?P U$2&.;& $2&6$=;.;&6$&; 9$A&.$$&
5ip Prt TH F$3F' F73F2
'2h :rine U$=& mg 7&& mg 7>= # =>& g
<.a3 vision changes Jo no yes
H:L pain Jo no yes
<ELLP3 LCT increased Jo no yes
 E#-OLOGY: vasospasm; inc> thrombo+ane; trophoblast invasion of spiral arteries
 recurrence of pre E in subse0uent pregnancy is 4A @ DDI
 ,eta' Co*!'i(ations: prematurity3 dec blood flow to placenta; abruption.fetal distress3
/:GH3 oligohydramnios
 SS: htn3 proteinuria in third trimester
 B)en severe3 can get severe h.a3 vision changes3 sei*ures (eclampsia!
 +,: nulliparous3 92& yo3 African American3 chronic htn3 chronic renal d*3 antiphospholipid
sd3 twin gestation3 angiotensin gene T'7=3 -LE
 #7: de'ivery is t)e G(ureH
MgSOE (always chec) refle+es and respirations when on Dg3 need good :MP!
2>1 # 1>2 mg.ml: therapeutic
1 ,J- depression
$& Loss of dtrIs
$= Hespiratory depression.paralysis
$8 ,oma
'& ,ardiac Arrest
<ydrala*ine to control ?P over $A&.$$&
 ECLAMPS-A: pre eclampsia plus sei*ures
o ,an have cerebral herniation3 hypo+ic encelphalopathy3 aspiration3
thromboembolic events
o -ei*ures are tonic clonic: '=N prelabor. =&N labor . '=N after labor (even 86$&
days!
o T+ of sei*ures: Dg-o2 (membrane stabili*ation!3 4alium /4
 %ELLP: hemolysis3 elevated liver en*ymes3 low platelets
o :sually in the severe pre E classification
o T+: delivery3 Dg-o23 hydrala*ine
 C)roni( %tn: U'&w EGA3 9Aw post partum; $.7 can get superimposed pre E; inc ris) of
abruption3 5/, acute tubular necrosis3 inc> prematurity . /:GH
o #7: procardia (,,?!3 methyldopa3 ? bloc)ers3 J-Ts at 72 wee)s
Diabetes in Pregnan(y
Priscilla @hite ,lassification: not used as much anymore
A$ diet controlled G5D (gestational diabetes mellitus!
A' G5D controlled with insulin; polyhydramnios3 macrosomia3 prior stillbirth
? 5D onset 9 '& yo; duration U $&y
, onset $&6$; yo; duration U '& y
5 Kuvenile onset dur 9 '& y
C nephropathy
H retinopathy
D cardiomyopathy
T renal transplant
 Etio'ogy : impairment in carbohydrate metabolism that manifests during pregnancy ;
=&N in subse0uent preg ; many get 5D later in life>
 +is2 ,a(tors: 9'= yo3 obesity3 family history3 prev infant 92&&& g3 prev> stillborn3 prev>
polyhydramnios3 recurrent Ab
 Assn <it): 2+ more pre e3 '+ more - Abs3 inc> inf+3 inc> hydramnios3 c.s3 pp hemorrhage3
fetal death
 ,eta' ano*a'ies:Transpostion of the great vessels3 sacral agenesis3 macrosomia3 still
birth
 D7: MI-ullivan (=& g glucose! O'1 w over $2&: fasting U$&=3 $ hr U$;&3 ' hr U$A=3 7 hr
U$2=
 Manage*ent: A5A $1&& # ''&& )cal.d diet; glucose chec)s3 insulin if necessary3 deliver
O 7162& w oral glucose tolerance test after delivery in si+ wee)s
 Antenata' testing: O 7&67' w :- 0 2w (loo) for /:GH3 polyhydramnios!3 )ic) counts3
J-T3 ?PP
 @atch for neonatal hypoglycemia
.#- $ Pye'one!)ritis
 Asy*!to*ati( Ba(turia: 9 $&&3&&& colonies =N of pregnancies; increased susceptibility
to cystitis and pyelonephritis ($=N complicated by bacteremia3 sepsis3 AH5-!; treat as
bacturia because of ris)s of preterm labor assn with pyelonephritis>
 Causes: -taph saprophyticus3 ,hlamydia3 E ,oli3 Plebsiella3 Pseudomonas3
Enterococcus3 Proteus3 ,oag # staph3 group ? strep
 SS .#-: dysuria3 fre0uency3 urgency
 D3 .#-: :.A F nitrite3 @?, esterase3 bacteria (contaminated if inc> epithelial cells!
 #3 .#-: (pregnancy!: Dacrodantin
 SS Pye'one!)ritis: ,4A tenderness3 fever3 dirty :A (need '.7 of criteria to diagnose!
 #7 Pye'one!)ritis: /4 Ancef until afebrile + 21 hours then 86$2 d po Pefle+
 Pyelo is more li)ely to occur on the H because the uterus is de+trorotated>
ProgesteroneIs effects cause urinary stasis3 which can predispose to pyelonephritis>
-nfe(tions and Pregnan(y
Ba(teria' &aginosis: Gardnerella vaginalis
 ss: gray.yellow malodourous discharge # clue cells on wet prep
 t+: Detronida*ole (flagyl! in second or third trimester
Grou! B Stre!: Assn with :T/3 ,horioamnionitis3 endometritis3 neonatal sepsis
 '67.$&&& live births assn with G??- sepsis
 /4 pen G or ampicillin in delivery
%er!es Si*!'e3 &irus: a 5JA virus (<-4 $ and '!
 /f mom has lesions  can give baby viral sepsis on the way out  herpes encephalitis
 #3: /4 Acyclovir3 , -E,T/MJ if active lesions
&ari(e''a /oster &irus
 4ertical transmission possible
 /f mom gets chic)en po+ during pregnancy the baby could die
 #7: varicella *oster immune globulin given to mom within 8' hours of e+posure; can also
give to infant>
CM&
 SS baby: hepatosplenomegaly3 thrombocytopenia3 Kaundice3 cerebral calcifications3
chorioretinitis3 interstitial pneumomitis3 DH3 sensorineural hearing loss3 neuromuscular
d.o
+ube''a
 SS adu'ts: maculopapular rash3 arthralgia3 lymphadenopathy for '62 d
 SS infant: deafness3 ,4 anomalies3 cataracts3 DH
 D3: /gD titers in infant
 5o not give DDH vaccine to pregnant woman
 Jo t+ for rubella
#o3o!'as*osis
 ,irst tri*ester infe(tion: chorioretinitis3 microcephaly3 Kaundice3 hepatosplenomegaly
 Adu't SS: fever3 malaise3 lymphadenopathy3 rash
 D3: percutaneous umbilical cord sampling3 /gD ab
 #3: pyrimethamine (U$2 w!3 spiramycin (less teratogenic!
%e!atitis B
 #rans*: se+3 blood products . transplacental; can cause mild to fulminant hepatitis
 D3: ab mar)ers: <bs Ag
 4accinated at birth now
Sy!)i'is
 4ertical transmission possible in primary and secondary syphilis
 SS baby: hepatosplenomegaly3 hemolysis3 LA53 Kaundice3 saber shins
 D3: /gD antitreponemal ab
%-&
 4ertical transmission possible; AVT decreases chances GHEATLS
 /nc transmission with inc viral burden.adv disease
Neisseria gonorr)ea
 Transmitted during birth to eye3 oropharny+3 e+t ear3 anorectal mucousa
 5isseminates  arthritis3 meningitis
 -creening in early pregnancy
 #3: ceftria+one3 -upra+ po
C)'a*ydia
 2&N babies get conKunctivitis
 $&N babies get pneumonitis
 #3: Vithroma+3 erythromycin
%y!ere*esis Gravidaru*
 Dorning sic)ness is found in 1&N of women3 but usually resolves by $Aw
 <yperemesis: more pernicious vomiting assn with weight loss3 electrolyte imbalances3
dehydration3 and if prolonged3 hepatic and renal damage>
 #3: maintain nutrition3 J- with =N de+trose3 compa*ine3 phenergan3 reglan /4./D; if
needed TPJ (total parenteral nutrition!
Coagu'ation Disorders
 A hypercoaguable state can be due to inc> coag factors (all e+cept $$3 $'3 dec turnover
time for fibrinogen!3 endothelial damage3 and venous stasis (uterus compresses /4, and
pelvic veins!  increased deep venous thromboses3 septic pelvic thromboses and
pulmonary emboli>
 Se!ti( !e'vi( t)ro*bosis: postpartum3 prolonged fever on antibiotics; usually due to
ovarian veins; not li)ely to lead to emboli; t3 is heparin3 ab+
 Dee! &enous #)ro*boses: --: edema3 erythema3 palpate venous cord3 tender3
different calf si*es; 5+: 5oppler of e+tremity3 venography; T+: heparin /4 (PTT + '! then
sub L heparin or loveno+ in pregnancy (JM ,M:DA5/J /J PHEGJAJ,S: s)eletal
anomalies3 nasal hypoplasia!; coumadin MP if post partum>
 Pu'*onary E*bo'us: 54T  right atrium  H4  pulmonary arteries  pulm htn3
hypo+ia3 H<C  death>
--: sob3 pleuritic chest pain3 hemoptysis3 with signs of 54T
5R: 5oppler e+t3 ,RH3 E,G3 4L -can3 -piral ,T Pulmonary Angiography
TR: /4 heparin then -L heparin or loveno+ (coumadin MP postpartum!
Substan(e Abuse
 EtO%: Cetal Alcohol -d: growth retardation3 ,J- effects3 abnormal facies3 cardiac
defects
#3: alcoholism: aggressive counseling; ade0uate nutrition
 Caffiene: 1&N e+posed in first trimester
 #oba((o: /nc> -ab3 preterm birth3 abruption3 dec> birth weight3 -/5s3 resp disease
 Co(aine: inc> abruption (from vasoconstriction!3 /:GH3 inc PTL; as a child3
developmental delay
 O!iates: (heroin.methadone!; the danger is heroin withdrawal3 not use  miscarriage3
PTL3 /:C5; t3: enroll in methadone program; do not restart methadone if patient has not
used for 21 hours>
Post!artu* Care
 &agina' de'ivery: pain care.perineal care (ice pac)s3 chec) for hemorrhage3 stool
softener Pelvic rest + A w (no douching3 tampons3 se+!; J-A/5-
 C Se(tion: local wound care3 narcotics for pain3 stool softeners3 J-A/5-
 Breast Care: Dil) letdown occurs at '2 # 8' hr; if not breast feeding use ice pac)s3 tight
bra3 analgesia (breast feeding gives relief!
 Mastitis: oral or s)in flora enter a crac) in breast s)in; can be treated with diclo+acillin;
"ontinue to breast feed-
 Contra(e!tion: no diaphragms3 caps until A w; if breast feeding  depo3 micronor; not
breastfeeding  M,P3 norplant3 depo3 Mrthoevra
 Post Partu* %e*orr)age:
o ?lood loss vag delivery ( =&& cc; c.s ( $&&&cc (normal # remember3 momIs
plasma volume e+pands Kust for this reason%!
o Causes:
 :terine atony (HC: multip3 h.o atony3 fibroids! t+: pitocin3 methergine3 etc>
 Hetained products of conception: find on manual e+ploration of uterus
 Placenta accreta: placenta is stuc) in uterine wall
 ,erv.4ag lacs: repair with ade0uate anesthesia
 :terine rupture ($.'&&&! ss: abd pain3 “pop t+: laparotomy and repair if
possible>
 :terine /nversion ($.'1&&! HC: fundal placenta3 atony3 accreta3 e+cess
cord traction t3: *anua''y revert3 JTG3 Laparotomy
 Post Partu* de!ression:
o Post partum blues: =&N; changes in mood3 appetite3 sleep3 will resolve
o Post Partum depression: =N; decreased energy3 apathy3 insomnia3 anore+ia3
sadness; can get better or proceed to psychosis; t+: antidepressants (--H/s!
 Endo*etritis: a polymicrobial infection invading the uterine wall after delivery;
o --: fever3 inc @?,3 uterine tenderness (O =6$& d pp!3 foul discharge
o Loo) for retained products  do a d Q c
o T+: triple antibiotics until afebrile + 21 hours and pain gone>
GYNECOLOGY
Benign Disorders of Lo<er Genita' #ra(t
Congenita' ano*a'ies:
 Labia' fusion: assn with e+cess androgens  develop abnormal genitalia t3: estrogen
cream
 -*!erforate )y*en: the Kunction between the sinovaginal bulbs and the :G sinus is not
perforated  obstructs outflow
o --: primary amenorrhea at puberty3 hematocolpos (blood behind hymen!
o TR: surgery
 &agina' se!tu*s: when vagina forms3 the sinovaginal bulbs and mullerian tubercle must
be canali*ed> /f not you get a transverse vaginl septum between lower '.7 and upper $.7
 primary amenorrhea
o TR: surgery
 &agina' agenesis: Ho)itans)y6Puster6<auser -d: mullerian agenesis.dysgenesis; may
have rudimentary pouch from sinovaginal bulb; Testosterone /nsensitivity: 2A +y with no
sensitivity to testosterone (may have undescended testes!
o TR: surgical creation of vagina
 &u'var dystro!)y: <ypertrophic: from chronic vulvar irritation ( raised white lesions
o TR: cortisone cream bid
o Atrophic: dec estrogen to local tissues (postmenopausal!
o --: dysuria.parunia3 pruritus3 4ulvodynia3 lichen sclerosis et atrophicus
o T+ : 'N testosterone cream3 hydrocortisone cream
 Benign Cysts:
o Epidermal ,yst: occlusion of pilosebaceous duct.hair follicle
 T+: incision and drainage
o -ebaceous cyst: duct bloc)ed # sebum accumulates
 TR: / Q 5 if infected
o Apocrine -weat Gland ,yst: on mons or labia  occludes glands 
superinfection  hidradentitis suppurative  / Q 53 5o+ycycline
o ?artholinIs gland ,yst: 2 or 1 oIcloc) on labia maKora
 TR: sit* baths3 inf+ # / Q 5 . word catheter
 Cervi(a' Lesions
o ,ongenital anomalies: 5E- e+posure in utero ( '=N congenital anomalies3 clear
cell adenocarcinoma $N
o ,ervical ,ysts: dilated retention cysts: nabothian cysts ( bloc)age of
endocervical gland O $ cm # as+3 no TR
o Desonephric ,ysts: (remnants of wolfian.mesonephric ducts! deeper in stroma
o Polyps: broad based ( can have intermittent.post coital bleeding; usually
removed cervical fibroids ( intermenst bleeding3 dysparunia3 bladder.rectal
pressure. r.o cerv can
o ,ervical -tenosis: congenital or after scarring (surgery.radiation! or secondary to
neoplasm or polyp; if asymptomatic3 leave alone; if causes menstrual problems3
remove; gently dilate scarring>
,ibroids
 Cibroids ( Estrogen dependant local proliferation of smooth muscle cells3 usually occur in
women of child bearing age and regress at menopause; African American are at higher
ris); has a pseudocapsule of compressed muscle cells; are found in '&67&N American
women at age 7&
 SS: menorrhagia (submucous!3 metrorrhagia (subserous3 intramural!3 pressure s+ (from
pressing against bladder!3 infertility; =&N are asymptomatic>
 Parasitic fibroids: get their blood supply from the omentum>
 %isto'ogi( C)anges:
o <yaline ,hange
o ,ystic ,hange
o ,alcific change
o Catty ,hange
o Hed.white infarcts
o -arcomatous change (most rare!
 /n pregnancy are at increased ris) for -ab3 /:GH3 PTL3 5ystocia; may grow during
pregnancy
 Med #7: 5epo provera3 Lupron (GnH< agonist!3 5ana*ol
 Surg #3: momectomy(only for fertility purposes!3 )ystere(to*y indi(ated <)en ane*i(
fro* b'eeding severe !ain siFe J 54 < urinary freKuen(y gro<t) after
*eno!ause3 new role for emboli*ation by interventional radiology
Endo*etria' %y!er!'asia
 Endometrial hyperplasia: abnormal proliferation of gland.stromal elements;
overabundance of histologically normal epithelium
o -imple without atypia: $N cancer6 Provera
o ,omple+ without atypia: 7N cancer6 Provera
o -imple with atypia: ;N cancer6 Provera vs> TA<
o ,omple+ with atypia: '8N cancer6 TA<
o HC: unopposed estrogen3 P,M3 granulosa.theca tumors
o 5R: endometrial biopsy
Endo*etriosis
 Adeno*yosis: Endometrium in myometrium
o :susally a 7& yo multiparous woman with heavy #ainful #eriods3 enlg tender
uterus described either as boggy.soft or woody.firm and pelvic heaviness
o H+: hysterectomy . analgesics
o The tissue does not undergo proliferation phase of cell cycle>
 Pe'vi( Endo*etriosis: presence of endometrial glands outside of endometrium
o Theories
 -ampsonIs reflu+ menstruation: most li)ely
 ,oelomic metaplasia: irritant to peritoneum
 Camily history . genetic
 /mmunologic
 Lymphatic and vascular mets
 /atrogenic dissemination (ie:you see it on the other side of a c section
scar!
o /nduces fibrosis which causes pelvic pain
o SS: pain3 infertility3 bleeding.ovarian dysfunction3 hematoche*ia. hematuria3
dyspareunia (pain with se+!
o ,an be on peritoneum3 ovary (chocolate cysts!3 round ligament3 tube3 sigmoid
colon
o D7: laparoscopy
o #7:
 J-A/5
 M,P.Provera
 Lupron (GJH< agonist! # pseudomenopause
 Laser surgery.coagulation of implants3 TA<.?-M
Ovarian Cysts
 :sually follicular from failure of follicle rupture; disappear in A& d
 7 # 1 cm
 Types:
o ,orpus luteum cysts (firm.solid!
o ,ystic.hemorrhagic (hemoperitoneum!
o Theca lutein (bilateral3 filled with straw fluid; high b<,G!
 D7: ultrasound3 ,A$'= in cases suspect for epithelial ovarian cancer
 DiffD7: ectopic3 tuboovarian abscess3 torsion3 endometriosis3 neoplasm
 #7: if premenopausal3 can observe if under 1cm; /f postmenopausal (any si*e! or
premenopausal need laparoscopy vs> laparotomy for cystectomy or oopherectomy
#reat*ent of S#Ds
 C)'a*ydia tra()o*atis:
o 5R # 5irect fluorescent Ab
o #3: do+ycycline $&& mg bid + 8 d or A*ithromycin $ g po (one dose!
 NC Gonorr)ea:
o 5R: gram stain3 culture
o HC: low -E-3 urban3 nonwhite3 early se+3 prev gon inf+
o Treat both partners
o #7: Hocephin '=& mg /D or ,ipro =&& mg po or Clo+in 2&& mg po
o :sually transfers male to female more than female to male>
 Sy!)i'is: Treponema pallidum
o 5R: dar) field microscopy
o #7: (U$ yr duration! Pen G '>2 million : /D (9$yr duration! '>2 mill : /D + 7
doses (see ob section for full description!
 %er!es Si*!'e3 &irus: first episode # Acyclovir.Camciclovir.4alcyclovir; AAN <-46'
77N <-46$ of genital herpes; vesicles rupture in $&6'' d leaving a painful ulcer; can use
antivirals also as suppressing agents as the virus hangs out in the dorsal root ganglion>
 %P&:
o Types A.$$ ( genital warts
o Types: $A3$137$ ( cervical cancer
o TR: podofilo+3 cyrotherapy3 podophyllin rein3 T,A3 Aldara cream
 C)an(roid: casued by <aemophilus ducreyi; is a painful soft ulcer with inguinal
lymphadenopathy; t3 with ,eftria+one '=& /D + once or A*ithromycin $ g once po or
Erythromycin; treat partner>
 Ly*!)ogranu'ona veneru*: primary ( papules.shallow ulcer; secondary ( painful
inflammation of inguinal nodes with fever3 h.a3 malaise3 anore+ia; Tertiary ( rectal
stricture.rectovaginal fistula. elephantiasis #7: do+ycycline $&& mg po bid + '$ d
 Mo''us(u* (ontagiosu*: po+ virus from close contact; $6= mm umbilicated lesion
anywhere but the palms or soles; are asymptomatic and resolve on their own
 P)t)ris !ubis/sar(o!tes s(abei: Lice and scabies3 respectively; TR: lindane.Pwell
&aginitis
 Candida:
o HC: Ab+3 5D3 Pregnancy3 immunocompromised
o --: burning3 itching3 vulvitis3 cottage cheese discharge3 dysparunia
o 5R: wet prep PM< ( branching hyphae
o E+am: white pla0ues with or without satellite lesions
o #7: over the counter creams wor) well (monistat!; if resistant3 5iflucan $=& mg
po + once
 #ri()o*onas: unicellular flagellated proto*oan
o --: itching3 inc> discharge (yellow.gray.green!3 frothy
o E+am: strawberry cervi+3 foamy discharge
o 5R: see the buggers *ipping all over your wet prep
o #7: Clagyl =&& mg po bid + 8 d. partner condom + ' w
o Jote: avoid flagyl in frist trimester
 Ba(teria' vaginosis: Gardnerella vaginalis
o --: odorous discharge
o 5R: whiff test by adding PM<; see clue cells on wet prep (spotty s0uamous cells!
o TR: flagyl =&&mg bid + 8 d
o Jot an -T5
 Atro!)y
o --: burning d.c on se+
o HC: post menopausal
o TR: estrogen
P-D
Organis*s: Jeisseria3 ,hylamadia3 Dycoplasmia3 :reaplasma3 ?acterioides3 among others
S7: diffuse lower abdominal pain3 vaginal discharge3 bleeding3 dysuria3 dyspareunia3 ,DT3
adne+al tenderness3 G/ discomfort
D7: Cervi(a' Motion #enderness Adene3a' tenderness dis()arge fever e'evated BBC
ES+
Lab: cultures3 pelvic :.- if mass palpated3 rise in @?, count
#7: Ceftia0one 2 $ I. 1 12! Do0y"y"line 122 m$ I. or Clindamy"in 3 4entamy"in
Usually t0 for )5 hrs I. then if afebrile "han$e to Do0y"y"lin 122 m$ #o bid 0 1) d
#OA : Tubo Mvarian Abcess: persistent P/5 progresses to TMA in 76$AN of the time
Adne+al mass.fullness (not walled off li)e true absess!
5R: :.-3 Pelvic ,T if obese3 increase @?, with a shift to the left3 increase E-H
TR: 6os#itali7e for I. antibioti"s 8Tri#les& am#i"illin! $entamy"in! "lindamy"in9 if T%: ru#tures or
doesn;t resolve ,ith antibioti"s then sur$ery-
ENDOME#+-#-S: usually after some type of instrument disruption of the uterus: ,6section3
vaginal delivery3 5 Q E.,3 /:5!
5R: endometrial or endocervical culture will result in s)in3 G/3 repro flora
TR: Do0y"y"line vs- I. ab0
#O7-C S%OC" SYND+OME: vaginal infection that is not associated with menstruation
,an be assoc with delivery3 c6sections3 post partum Endometritis3 sab or laser t+ of coac
Sta!) aureus !rodu(es e!ider*a' #SS #85 t)at !rodu(es fever eryt)e*a ras)
desKua*ation of !a'*er surfa(es and )y!otension> Also see G/ disturbances3 myalase;
mucus membrane hyperemia3 change in mental status
Labs: increased ?:J.,H3 decreases plt; but neg b'ood (u'tures
TR: al,ays hos#itali7e< may need ICU and $ive I. fluids and = or #ressors- :>? do not shorten
the len$th of the a"ute illness but does de"rease the ris' or re"urren"e-
BLADDE+ ANA#OMY
6 5etrusser and urethra ( smooth muscle
6 /nternal spincter is at urethrovesical K+n
6 /ncontinence ( intraurethral U intravesical pressure
8 PSNS (-'3732! allows micturition : ,<ML/JEHG/, HE,EPTMH-
8 SNS # hypogastric n> T $& # L' prevents urination by contracting bladder nec) and internal
spincter : JE HE,EPTMH-
6 -omatic controls e+ternal spincter (pudendal nerve!
PEL&-C +ELA7A#-ON: damage to the anterior vaginal wall leading to cystocele3 endopelvic
fascia leading to rectocele or enterocele or stretching of cardinal ligaments which can lead to
uterine prolapse
D7: mostly PE : called a PMP L3 which is a graph on which certain points corresponding to
lengths of the vagina and where it moves on valsalva are graphed> This tells you where the defect
is3 so you )now the appropriate therapy from it>
S7: pain3 pressure3 dyspareunia3 incontinence3 bowel or bladder dysfunction
Causes: anything that will cause chronically increased abdominal pressure: cough3 straining3
ascites3 pelvic tumors3 heavy lifting
+,: aging3 menopause3 traumatic delivery3 associated with multiparity
PE: pelvic e+am shows the amount of descent of the structure into the vagina and thus
determines the degree of rela+ation: (PMP L!
-tage $ # upper '.7 of vagina
-tage ' # to the level of the introitus
-tage 7 # outside of the vagina
#7: )egels (contraction of levator ani muscle3 instructed by physician!3 estrogen replacement3
vaginal pessaries3 surgery
-NCON#-NENCE:
.+GE -NCON#-NENCE: a)a detrussor instability
S7: urgency3 often can not ma)e it to the bathroom
Causes: foreign body3 :T/3 stones3 ,A3 diverticulitis
D3: based on history3 can be shown on urodynamics (which is a catheter in the bladder3 rectum
and a machine to measure the difference> The bladder is filled with normal saline and response to
that is measured>!
.rodyna*i(s s)o<s: involuntary.uninhibited bladder contractions
#7: Pegle e+ercises3 anticholerginics (ditropan3 amytriptaline!3 muscle rela+ants3 beta agonists3
estrogen replacement6 surgery is not used here3 more medical therapy is appropriate
S#+ESS -NCON#-NENCE:
S7: involuntary loss of urine when there is an increased abdominal pressure mostly from
snee*ing3 coughing3 laughing which transmits pressure to the urethra
Me(): /ntrinsic spincter defect3 hypemobile bladder nec)3 pelvic rela+ation
Causes: trauma3 neurologic dysfunction3 associated with multiparity
#7: Peglele+ercises3 alpha agonists3 estrogen cream3 retropubic urethrope+y (which is a surgery
where the periurethral tissue is Koined with the ,ooperIs ligament # called a Bur()! or #rans
&agina' #a!e procedure (the periurethral tissues are raised towards the abdominal wall using a
mesh sling6 placed under local anesthesia!
O&E+,LOB -NCON#-NENCE:
S7: dribbling3 urgency3 stress
Me(): underactive detrussor leading to poor or absent bladder contractions
Cause: 5D3 drugs3 fecal impaction3 D-3 neurologic
#7 : treat underlying cause3 <ytrin3 bethanechol3 intermittient cath3 dantroleen
D7: urodynamics3 post void residual (after you pee3 you place a catheter to see how much urine
is left in the bladder6 over $&& cc is abnormal!
.+-NA+Y ,-S#.LA: produces continuous urine lea)age commonly seen following pelvic
surgery.radation
HC: P/53 radiation3 endometriosis3 prior surgery
5R: Dethylene blue dye inKection into the bladderWplace a tampon in the vagina6 if itIs a
vesicovaginal fistula the tampon will be blue3 indigo carmine dye given /4 with a tampon in vagina
Wif itIs a ureterovaginal fistula the tampon will be blue
TR: surgery but must wait 7 # A months to repair postsurgical fistulas
ENDOC+-NOLOGY
P.BE+#Y: secondary se+ characteristics3 growth spurt3 achievement of fertility
$> Adrenarche (A61 yo!: regenerates *ona reticularis that produces 5<EA6-3 5<EA3
androsteinone
'> Gonadarche (yo!: pulsatile GnH< secretion goes to ant pituitary to secrete L<3 C-<
7> Thelarche (breast3 $$ yo!: Tanners stages
2> Pubarche ($' yo!: pubic hair3 A+illary hair
=> Growth spurt: (;6$7 yo!: increase G< and somatomedian # , result in pea) height velocity3
increase estrogen levels3 fusion of growth plate
A> Denarche: ($' # $7 yo!: anovulatory period up to $ year3 may ta)e ' years to have regular
cycle3 delayed in athletes
Two pneumonics: (pic) your favorite! “breast hair grow bleed or “boobs pubes pits and pads
#ANNE+ S#AGES
?reast <air
$> Prepubertal $> prepubertal
'> ?reast bud '> prese+ual hair
7> ?reast elevation 7> -e+ual hair
2> Areolar Dound 2> Did6escutcheon
=> Adult ,ontour => Cemale escutcheon
MENOPA.SE: cessation of menstruation
Onset # usually =&6 =$ years
6 if U2& yrs premature menopause
6 if U7= premature ovarian failure (idiopathic3 send genetic studies!
S7: irregular menses3 hot flashes secondary to decreased estrogen3 mood changes3 depression3
lower urinary tract atrophy3 genital changes3 osteoporosis
LABS: C-< 9 2&3 elevated L<3 decreased estrogen resulting in decreased negative feedbac)
D7: < Q P (PE shows decreased breast si*e with vaginal3 urethral3 and cervical atrophy ' to
decreased estrogen!
#7: <ormone replacement (<HT! primarily estrogen and progesterone if pt has uterus; calcium3
4it 53 e+ercise to counter the decreased osteoclast activity: Estrogen cream to counter act
vaginal atrophy>
Contraindi(ations: 4aginal bleeding3 thromboembolic d*3 breast ca3 uterine ca
Uno##osed estro$en 8estro$en ,ithout #ro$esterone in ,omen ,ithout a uterus9 results
in endometrial hy#er#lasia and C:-
ConseKuenses of de(reased estrogen:
6 unfavorable lipid profile that could result in stro)e and D/
6 /ncreased bone resorption b.c estrogen decreases osteoclast activity predisposing to hip fract>
6 Atrophy of s)in and muscle tone>
WHI Study: What are all these questions about estrogen and progesterone on the news? /n
women with active heart disease3 estrogen and progesterone (prempro! increases the remote ris)
of stro)e and 54T> There were problems with this study3 however>
There are no problems ta)ing estrogen alone when you donIt have a uterus>
P+-MA+Y AMENO++%EA: Estrogen  gives breasts; S chromosome ma)es Dullerian
/nhibitory Cactor6 no uterus if D/C present>
$> No Breasts L uterus: no estrogen
a> C-< high: ovarian failure (hypergonadotropic hypogonadism!
i> #urner0s : ovaries undergo rapid atresia
ii> Dosaic
iii> 5M )ydro3y'ase def : D/C produced so no female internal organs
ivC Pure Gonada' dysgenesis
b> C-< low: insufficient GnH<3 hypo pituitarism3 -wyerIs -d: Gonadal agenesis3
2A+y3 testes do not develop b.c D/C not released3 infertility3 e+ternal female
genitalia3 no breast>
'> LBreast @ uterus: estrogen F D/C
a> +o2itans2y "uster %auser: uterovaginal agenesis with other anomalies 2A++
b> Androgen insensitivity: 2A+y3 testicular femini*ation3 no receptors for
testosterone3 D/C secreted therefore no mullerian structures>
7> @Breast @ uterus: +y (no steroids! but phenotypically female3 no internal female organs>
a> 5M )ydro3y'ase def (steroid synthesis! in RS
2> LBreast @ uterus:
a> /mperforate hymen # solid membrane across introitus3 pelvic.abd pain from
accumulation of menstrual fluid # hemato colpos>
b> Trans vaginal septum # failure to fuse mullerian determined upper vagina and
:G sinus found at mid vagina t+: surgery
c> 4aginal agenesis HP<3 mullerian agenesis.dysgenesis uterial of partial
vaginagenesis3 no patent vagina3 2A++3 and ovaries and uterus on :.-> T+:
surgery>
SECONDA+Y AMENO++%EA:
 Dust do a good <QP to chec) for stresses3 wt loss.gain3 drugs3 e+ercise3 upt3 Estradiol
level3 progesterone challenge
 Enough estrogen (bleeds with progesterone challenge! chec) C-<3 L<3 PHL
o L< high thin) P,M
o L< wni thin) hypothalamic amenorrhea so stress3 e+ercise3 post pill
o PHL increased thin) prolactinoma3 hypothyroidism3 prenothra*ines3 pregnancy
 Jo estrogen (no bleed with progesterone challenge! chec) C-<3 L<3 PHL
o C-< high thin) ovarian failure3 resistant ovarian syndrome
o C-< low # wnl chec) DH/.,T for pituitary tumors3 -heehanIs -immans syndrome
o ,ould also be post surgery problems:
 AshermanIs following 5Q,
 ,ervical stenosis following ,P,
S<yer0s Syndro*e: 2A+y3 gonadoagenesis3 w.o testes no D/C yielding female genitalia but no
estrogen so no breasts>
"a''*an0s Syndro*e: absence of GnH< and anosomia> Pts have breast and uterus
Testicular Cemini*ation: 2A+y insensitive to testosterone> D/C so no internal female genital
structures F estrogen so has breasts>
PMS
'
nd
X of cycle
Probable ,auses: abnormal estrogen.progesterone balance3 increase PG production3 decrease
endogenous endorphins; disturbance in renin6angiotensin6aldosterone system
5R: = of $' symptoms (including $ of the first four!
-R:
$> 5ecreased mood
'> An+iety
7> Affective Liability
2> 5ecrease interest
=> /rritability
A> ,oncentration difficulty
8> 5ecreased energy
1> ,hange in appetite
;> Mverwhelmed
$&> Edema
$$> Edema
$'> @eight gain
$7> ?reast Tenderness
T?: avoid "affeine! etoh! toba""o! lo, sodium diet! ,ei$ht redu"tion! stress mana$ement-
Dru$s& @S:IDS! %CPs! lasi0! "al"ium! vit E! SS/I
DYSMENO++%EA: pain and cramping during menstruation that interferes with the acts of daily
living>
Primary # presents U'& years b.c of increased PG occurs with Mvulatory cycles
-econdary # Endometriosis3 Adenomyosis3 fibroids3 cervical stenosis (congenital3 trauma3
surgery3 infection!3 adhesions (h.o infection P/53 TMA3 e+ lap LMA!
MENO++%AG-A
 <eavy prolonged menstrual bleeding; over 1& cc. cycle
 Avg 7= ml of blood loss
 9 '2 pads per day
 Estrogen increases endometrial thic)ness
 Progesterone matures Endometrium and withdrawal of leads to secretion
 Denstruation at regular intervals usually indicates ovulation
Abnor*a' .terine B'eeding/D.B a)a irregular periods indicate anovulation
,auses: fibroids3 Adenomyosis3 endometrial hyperplasia3 endometrial polyps3 cancer3 pregnancy
complication
6 Puberty # give Cergon3 J-A/5- premarin until bleeding stops3 chec) 4on @illebrand Cactor
6 $A # 2& yo thin) endometriosis3 Adenomyosis3 fibroids T0& E>! %CPs
6 92& yo thin) endometrial cancer T?& E>! de#o #rovera! DAC! T:6
ME#+O++%AG-A: intermenstral bleeding thin) endometrial polyps3 endometrial.cervical cancer3
pregnancy complication
POLYMENO++%EA: cycles U'$ d between periods ( anovulation
OL-GOMENO++%EA: 97= d apart ( disruption of pit.Gonadal a+is3 pregnancy
D.B: abnormal uterine bleeding in absence of organic causes
O&.LA#O+Y D.B:
 Early spotting # estrogen no increasing fast enough
 Did spotting # estrogen drop off at ovulation
 Late spotting # Progesterone def
 TR: @S:IDS de" blood loss by 22BC2D
POS# MENOPA.SAL BLEED-NG
6 9$' months after menopause
6 lower.upper genital tract
Dech: e+ogenous hormones
Jon gyn causes: rectal bleeding3 prolapse3 fissures3 tumors vaginal atrophy3 ,A (endometrial and
cervical!3 endometrial
<yperplasia3 Polyps
5R: inspection on PE3 pap3 rectal3 ED?3 <-G3 <.<3 :.-
T?& ref all $i #roblems! sur$ery! estro$en re#la"ement! b0 all lesions
%-+S.-#-SM / &-+-L-SM
Diagnosis/ Bor2 u!: assess body hair systematically
Cree testosterone6 ovary produces the most testosterone
5<EA-6 adrena' produces the most 5<EA-6 screens for adrenal tumors
$8 hydro+y progesterone6 congenital adrenal hyperplasia
%air ty!e: 4illus hairs # cover entire body
Terminal hairs # thic) ( A+illary3 pubic3 = reductase converts testosterone to dihydrotestosterone
to stimulate terminal hair development
• %irsuitis* # increase of terminal hairs esp on face3 chest bac)3 diamond shaped
escutcheon (male! increase = reductase
• &iri'is* # male features3 deepening of voice3 balding3 increase muscle mass3
clitormegaly3 breast atrophy3 male body habitus
Causes: Adrenal tumor3 ovarian tumor3 P,M
,ushingIs syndrome: increase A,T<3 cortisol
,ongenital Adrenal <yperplasia # '$ and $$ hydro+ylase def
Po'y(ysti( Ovarian Syndro*e: This is a syndrome which can include numerous ovarian cysts3
but really is more than that> /t includes G
• /nsulin Hesistance: diagnosed by Casting Glucose. /nsulin ratio U2>= T+: etformin
• <irsuitism: from hyperandrogenemia
• Anovulation: irregular3 heavy periods; if desires fertility treat with metformin and "lomid
• C-< : L< ratio is over '>=:$
-N,E+#-L-#Y: inability to achieve pregnancy after $' months of unprotected intercourse3 '&N of
population
6 /diopathic6 $&N
6 Dale and Cemale6 $&N
6 ,e*a'e Causes # 2&N
Ovu'atory # Anovulation3 endocrine3 P,M3 premature ovarian failure
TR& ovulation indu"tion
8&N success
Clomid: antiestrogen that results in increased C-<3 more mature follicies and
ovulation se: hot flashes3 emotional liability3 depression and mult gestations
Per$onal: purified C-<.L< <DG /D inKection in follicular phase
1= # ;&N effective
/4C3 G/CT3 V/CT: ovulation induction3 harvest oocytes add sperm fertili*e place in
uterus>
#uba': adhesions3 endometriosis3 P/53 salpingitis
TR: tubal reconstruction
Peritonea': endometriosis3 adhesions3 P/5
.terine: ashermanIs3 fibroids
TR: myomectomy
Lutea' P)ase Defe(t TR: #ro$esterone durin$ and after "on"e#tion
Ma'e Causes: 2&N
TR: for all intrauterine insemination
DE5- that affect sperm analysis: cimetidine3 colchicines3 sulfasala*ine3 allopurinol3
erythromycin3 steroids3 tetracycline
,yptorcidism
4aricocele
Epidydimitis
Prostatitis
Bor2 .!:
-perm count6 must be done first
T-<3 Prolactin
<-G6hysterosalpingogram6 assesses patency of tubes and diagnoses intrauterine defects
Post ,oital test6 loo)s at 0uality of mucus and sperm3 done 5"$'6$2
??T6 temperature curve6 spi)e predictive of ovulation
Progesterone level on day '$6 assess ovulation
5iagnostic -cope6 loo)s for endometriosis
C%ANGES -N &.L&A
Li()en S('erosis # thin s)in3 hyalini*ed collagen t+: "lobetasol 8a hi$h #oten"y steroid9
E3tra*a**ary Paget0s # intraepithelial neoplasia of the s)in
9A& yrs w.vulvar purities
pale atypical cells with mitotic figure
'&N have adeno ca underneath
-R: pruitus unrelieved by antifungals
5R: biopsy
T?& ,ide lo"al e0"ision! Col#o
Assoc with other cancers: gi3 breast3 cv+ c.w chronic inflammatory changes
-car yields red velvet and white pla0ues on labia
/nfranodal spread li)ely to be fatal
&-N - -- --- : &.L&A+ -N#+AEP-#%EL-AL NEOPLAS-A: dysplasia of the vulva
6atypia3 thic)ened s)in
6degree proportioned to " of mitotic fig
6can see s0uamouspearls
6postmenopausal late =&6A&s
6correlated with <P4 1& # ;&N
6diffused focal raised3 flat3 white3 red3 brown3 blac)
-R: 4ulvodynia3 pruitus
TR:e0"ision ,ith s"al#el or laser3 f.u ,olpo 0 7 mo until disease free then 0 A mo
&.L&A+ CA # =N gyn malignancy
6associated with 5D3 <TJ3 obesity vulvardystrophies
-R: 4ulvodynia3 purities3 mass erythemia
5R: b+ : see epidermoid ;&N of cases3 melanoma =6 $&N3 basal '67N3 cauliflower hard indurated
-TAG/JG: / U'cm in si*e3 no nodes3 no mets
/a U$mm
/b 9$mm
// 9'cm3 no nodes3 no mets but can progress to perineum3 urethra and anus
/// unilateral nodes with any si*e
/4 bilateral nodes
TR: based on sta$e! from ,ide lo"al e0"ision to vulve"tomy to radi"al vulve"tomy=lym#h node
disse"tion
&AG-NAL CA
6women in their =&Is
65E- e+posure in utero resulting in clear cell adenocarcinoma
6asymptomatic for the most part but may have d.c3 bleeding3 purities
6TR: pap # ,olpo # pathologic d+
ABNO+MAL PAP SMEA+
6false negative pap 2&6=&N
• Gbenign (e''u'ar ()angesH : thin) infection so wet prep3 cultures
• 2oi'o(ytosis: pathologic description associated with <P4
• GASC.S: Atypical -0uamous ,ell <yperplasia of :ndetermined -ignificance:
o AI hide underlying severe lesions
o re#eat #a# in 3 months! Col#os"o#y if 2 :SCUSs
o consider <P4 typing
• GLGS-LH: Low Grade -0uamous /ntraepithelial Lesion: T+: Col#os"o#y
• G%GS-LH : <igh Grade -0uamous /ntraepithelial Lesion: T+: Col#os"o#y
Co'!os(o!y: magnifies region of cervi+ after stained with acetic acid> Areas of dysplasia stain
@</TE (aceto white focal lesion! and are biopsied> An endocervical curettage is also done>
#reat*ent of dysplasia is based on the bio!sy and ECC resu't> As a general ruleG
• Dild dysplasia: observation3 cryotherapy
• Doderate dyplasia: cryotheraphy or LEEP (loop electrosurgical e+cision procedure!
• -evere dysplasia: LEEP or ,old Pnife ,oni*ation
• /f E,, has dysplasia: ,P, or LEEP
• E indi(ations for C"C:
o Mi(roinvasion on bio!sy
o ECC <it) dys!'asia
o Pa! (o'!o dis(re!an(y: /f the pap smear does not correlate with the biopsy
results: ie> <G-/L with normal biopsy results3 you may have missed something
and need to do a ,P,
o -nadeKuate (o'!o: means that there is a lesion e+tending into the os or that you
could not visuali*e the whole lesion on colpo6 there may be something more
e+tensive there
CE+&-CAL CANCE+
Dost cancer occurs in transformation *one
Poilocyte: has viral particle
<P4 oncogenic 773 7=3 ='3$A3 $1 ordinary wart A3$$
S7: vaginal bleeding3 d.c3 pelvic pain3 growth on cervi+ may palpate.see mass on e+am
,lassic presentation: post coital bleeding3 pelvic pain.pressure3 abnormal vaginal
bleeding rectal.bladder s+

#y!es: -0uamous large cell3 )eratini*ing3 non6)eratini*ing3 small cell (worse prog!
Adenocarcinoma
Di+ed carcinoma
Glassy cell # occurs in pregnant women usually fatal
+,: tobacco " of se+ partners3 age of onset of se+3 " -T5s3 </4 (cervical ,A an A/5- defining
illness!
Staging # based on microinvasion so *ust do a (one : staged ,L/J/,ALLS
M carcinoma in situ
/ contained to cervi+
// carcinoma beyond cervi+3 no sidewall
// pelvic sidewall3 hydronephrosis
/4 e+tends beyond pelvis
#7: IaE "one bio#syF hystere"tomy 122D "ure
Ib=IIa E radiation! radi"al hystere"tomy ( ta)es uterus3 cervi+3 parametrium3 LJ!
IIb=III=I. E e0tensive radiation!"hemo
O&A+-AN #.MO+S
+,: family h+3 uninterrupted ovulation3 nulitips3 low fertility3 delayed childbearing3 late onset
menopause (M,s have protective effect!
S7: asymptomatic until advanced stages3 urinary fre0uency3 dysuria3 pelvic pressure3 ascites3 6 6
#y!es:
Nonneo!'asti( : only operate if postmenopausal or if theyIre over 1 cm
o Collicle cyst
o ,orpus luteum <ematoma
o P,M
o Theca lutein cysts: assn with <,G and L<
o Endometrioma
o Para ovarian cysts (mullerian!
E!it)e'ia' (1&N!
o -erous cystadenoma: papillary cystic malignant bilateral3 psammonma bodies
o Endometroid: solid
o Ducinous: cystic
o ,lear cell: associated with <obnail ,ells on path3 assn with 5E-
o ?runner: loo) li)e transitional epithelium: @althard Jests ;;N benign
o -:ET: solid undiff
Ger* Ce''
o 5ysgerminoma: younger people3 solid radiosensitive3 lymphocytic infiltrate
o Teratoma: ectoderm endoderm mesoderm3 Hoti)ans)yIs protuberance3 complications:
medi"al& struma ovarii3 autoimmune hemolytic anemia3 carcinoid
sur$ery: torsion3 acute abdomen
o Primary choriocarcinoma of the ovary false3 F :PT3 increased <,G
o Sol) -ac Tumor.Endodermal -inus: FACP.L5<3 F-chuller 5uval ?odies
o Di+ed germ cell: <,G3 ACP3 L5<3 ,A $'=
Stro*a'
6older women (=&61&!
6-e+ cords hormone production
o Cibroma: DeigIs syndrome: ovarian tumor3 r hydrothora+3 ascites
o Granulosa Theca # femini*ing3 late recurrence3 ,all E+ner ?odies3 produce large
amounts of estrogen>
o -ertoli Leidig # masculini*ing3 secrete testosterone3 ,rystaloids of Hein)e secrete
androgens
o Gynandroblastoma6 components of male and female
Ot)er
o <ilar ,ell: hillus3 androgenic3 small
o Pru)enberg: G/ metastasis
bilateral enlarged solid ovaries
signet ring cell associated with mucus
assn with gastric cancer
Ovarian Can(er Staging:
/ 6 growth to one.both ovaries
// # with e+tension to pelvic structures
/// # peritoneum
/4 6 distant mets
AdKuvant ,hemo: cisplatin and ta+ol
RHT in //.///
Collow ,A$'= because increased in 1&N
CA O, ,ALLOP-AN #.BES
6adeno ,A from mucosa
6disease progresses li)e ovarian ,A
6peritoneal spread
6ascites
6bilateral in $&6'&N results from mets often
6primary in very rare
6asymptomatic but may have vague lower abdominal pain and discharge
TR: TA<.?-M cisplatin3 cyclophosphomide RHT
#+OP%OBLAS#-C D-SEASE
Doles
Co*!'ete:
6U'& yrs or 92& yrs3 1&N of molar pregnancies
6,omplete E?33 (both + from sperm!
6worse b.c can transform into malignant6 '& N malignant
6no baby parts
-n(o*!'ete: Triploid (usually RRS!
6Day have baby parts
S7: early abnormal bleeding
6Large for dates
6F.6 grape tissue
6bilateral enlarged ovaries
6increased in Asians 1.$&&&
6early to+emia
6threatened A?
6hyperemesis3 hyperthyroid3 <TJ
+,: maternal age3 h.o hydatidiform mole3 recurrent -A?3 low social economic status3 poor
nutrition
#7: dilation and "uretta$e! "onsider hystere"tomy
,/.: monitor <,G for one year3 contraception for one year (b.c donIt want to confuse rising <,G
titers of a new pregnancy with those from molar pregnancy!3 pelvic e+ams 0 ' w)s until uterus
clear
,hemo: if increased <,G at A months3 lung or other mets3 recurrence
C%O+-OCA+C-NOMA: malignanancies in assn with pregnancy
6maKority follow trophoblastic moles3 but can follow normal pregnancy also
6$.'&3&&& pregnancies
HC: as above (A! women mating with (M! men
-R: abnormal bleeding after any pregnancy
TR:
Chemothera#y
1- T?
2- Eto#oside=a"tinomy"in D=T?
3- Cy"lo#hos#hamide=.in"ristine
D A C
CON#+ACEP#-ON
Hhythm
Certility awareness.abstinences
==61&N effective
ovulation assment ( ??T
menstrual cycle trac)ing
cervical mucus e+am
,oitus /nteruptus
@ithdrawal before eKaculation
$=6'=N failure
Lactational Amenorrhea
Jursing delays ovulation by hypothalamic suppression
Da+ of A months
=&N ovulate by A6$' months
$=6==N get pregnant while nursing
?arrier
Dale and female condom3 diaphragm3 cervical cap sponge3 spermacide
/:5
-permicidal inflammatory response. inhibition of implantation
:sed when M,Ps contraindicated
Patient is a low -T5 ris)
,ontraindicated in pregnancy3 abnormal vaginal bleeding3 infection
Helative contraindication: nullip3 prior ectopic3 h.o -T53 mod.sev dysmenorrhea
Cailure rate U'N
Jorplant: not sold anymore for monetary reasons only
-ustained release6 = years
&>'N failure
not many side effects b.c no estrogen only progesterone
si+ fle+ible rods (7Amg progesterone! -L upper arm
side effects: /rregular vaginal bleeding3 <A3 wt change3 mood changes
5eproprovera
Dedo+yprogesterone acetate
/D slow release of over 7 months
>7N failure rate
side effects: irregular menstrual bleeding3 depression3 weight gain
98&N get irregular menses3 eventually have amenorrhea
4asectomy
Ligation of the vas deferens
U$N failure rate
must use condom for 26A w)s until a*ospermia confirmed on semen analysis
8&N reanastomose resulting in pregnancy $16A&N
=&N ma)e anti6sperm antibodies
Tubal -terili*ation
Dost used method of birth control
2N failure rate
Jo side effects
Permanent although $N see) reversal which is successful in 2$612N
$.$3=&& ris) of ectopic
2.$&&3&&& mortality rate
Ora' Contra(e!tive Pi''s:
MEC%: Pulsatile release of C-< and L< suppresses ovulation
,hange in cervical in cervical mucus
,hange in Endometrium
#YPES:
Donophasic # fi+ed dose of estrogen and progesterone
Dultphasic varies progesterone dose each wee) and lower overall estrogen.prog
Progesterone progestin only not as effective as combination M,Ps
COMPL-CA#-ONS:
Thromboembolism ( do not give in women with family history of 54T or PE!3 PE3 ,4A3
D/3 <TJ
MEDS t)at De(rease Effi(a(y of OCPS:
P,J3 tetracycline3 rifampin3 ibuprofen3 dilantin3 barbiturates3 sulfonamide
OCP de(rease t)e effi(a(y of folates3anticoagulants3 insulin3 methyldopa3 phenothia*ine
Benefits of OCP:
5ecrease ovarian.endometrial ca 9BY A;INNN=3 ectopic3 anemia3 pid3 cysts3 benign breast
d*3 osteoporosis>
#%E+AP.#-C AB
 '=N of pregnancies end in therapeutic ab
 His) of death U $.$&&3&&& (anesthesia!
 4aginal evacuation # suction curettage3 5 Q ,.E
 /nduction of labor
 Dedical TR :
o Antiprogestin agent (H:621A # mifepristone : bloc)s effects of progesterone! $st
X of $st trimester>
o Post coital pill # high doses of estrogen that either suppresses ovulation or
accelerates ovum thru tube so no fertili*ation se: J.4
 4
nd
#er*
 ,ongenital anomalies
 4aginal prostaglandin
 5 Q E
 /nduction of labor w. hypertonic solution (saline3 urea3 PGC3 PGE vaginal suppositories!

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