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ObGyn Case Files 1

ObGyn Case Files



Case 1: Genuine Stress Incontinence: incontinence through the urethra due to sudden
increase in intra-abdominal pressure, in the absence of bladder muscle spasm
o Differential Diagnosis:
Genuine stress incontinence:
No delay in incontinence with valsalva
Urge Urinary Incontinence: requires urge or delay from a cough; due to
uncontrollable detrusor muscle contraction
Delay incontinence with valsalva
Overflow incontinence: associated with diabetes or neuropathy
Large post-void residual
o Physiology:
Normal: The pressure of the urethra and support from the pelvic diaphragm
is greater than the bladder pressure providing continence.
Normal: valsava cough intra-abdominal pressure is exerted on the
bladder and the proximal urethra providing continence
Adnormal: proximal urethra is outs the pelvic diaphragm. Valsalva
increases intra-abdominal pressure on the bladder, but the proximal
urethra causing incontinence
o Clinical Presentation:
Multiparous woman
Incontinence related to stress activities
No urge component and no delay from valsalva to drip
o Workup:
H and P, UA, and Post-void residual
GSI: 1) timed void and keigel exercises 2)urethropexy
UUI: anticholinergic to prevent detrusor muscle contraction
OI: catheter
o Treatment:
Urethropexy: movement of the proximal urethra back into the pelvic
diaphragm
Midurethral slings: mesh that is attached to act as a hammoack for the
proximal urethra
Transvaginal or transobturator
Case 2: Health Maintenance
o Health maintenance approach
Cancer screening, immunizations, addressing common diseases
o Primary Prevention: modifying risk factors
o Secondary Prevention: catches disease in the asymptomatic stage
o Table 2-1, page 34
o Clinical Pearls:
Most common COD in women <20 yo is MVA
Most common COD in women 49 CVD
Major conditions in the 65 age group
Osteoporosis, CVD, breast cancer and depression
Case 3: Uterine Inversion
o Differential Diagnosis:
Uterine inversion: ragged red mass
Vaginal or cervical prolapse: smooth appearance
o Clinical Presentation:
Third stage of labor:
Placenta cord has lengthened,
A small amount of blood from the vagina
ObGyn Case Files 2
Placenta with a ragged reddish mass around it
Due to traction of the umbilical cord without separation
o Treatment:
Anesthesiologist:
Possible emergency surgery
Halothane: relaxes uterus
Cupped glove technique to reposition the uterus
Start two IV lines
Relax uterus
Halothane, terbutaline, magnesium sulfate
After repositioning of the uterus give oxytocin
o Clinical Pearls:
Four signs of placenta separation
Gush of blood
Umbilical cord lengthening
Globular and firm shape of the uterus
Uterus rises to the anterior abdominal wall
Almost certain to have maternal hemorrhage
The fundus is the most likely site for placenta implantation leading to
uterine inversion
Abnormally retained uterus: labor stage 3 lasting greater than 30 minutes -
> next step: manual extraction
Placenta accreta: increase risk for intrauterine inversion
Case 4: Perimenopause (Climacteric)
o Clinical Presentation:
Irregular menses (anovulatory cycles)
Feelings of inadequacy (vasomotor symptom)
Hot Flushes (hypoestrogenism)
Pathologic fractures (hypoestrogenism osteoporosis) -> thoracic spine is
the most common area
Vaginal atrophy (decrease epithelial thickness)
o Workup:
FSH and LH levels: abnormally elevated because of no feedback inhibition
DEXA scan: BMD
Hypothyroidism, diabetes mellitus, HTN, and breast cancer
o Treatment:
Estrogen therapy:
Advantages: decreases fracture incidence and lower incidence of
colon and ovarian cancer; decreases incidence of hot flashses; with
progestin lowers incidence of endometrial cancer
Disadvantages: continuous therapy ->increases likelihood of CVS
and breast cancer
Short term, low dose
NOTE: FSH feedback is regulated by inhibin not estrogen so FSH
would still be elevated with estrogen therapy
Clonidine: antihypertensive that may be used to decrease hot flashes
Raloxifene:
Selective estrogen receptor modulator
Prevents bone loss, but does NOT treat hot flashes
Weight bearing exercises, Ca
2+
, Vit. D supplements -> maintain bone density
o Clinical Pearls:
Prolactinoma: hypothalamic dysfunction
Turners syndrome: ovarian failure
ObGyn Case Files 3
Marathon runner amenorrhea: hypothalamic dysfunction -> corrected with
weight gain
Sheehan syndrome:
Post-partum woman
Amenorrhea and unable to breast feed
Pituitary dysfunction
Case 5: Necrotizing fasciitis
o Clinical Presentation:
Present in septic shock: severe hypotension
Pathognomonic: crepitance
Hemoconcentration and renal insufficiency
Post-op: C-section or episiotomy
o Workup:
Diagnosis made on CP
o Treatment:
IV fluids immediately
May require pressors if IV fluids are not sufficient raise bp (i.e.
dobuatmine/dopamine)
Broad spectrum antibiotic (penicillin, gentamicin, and metronidazole)
Monitor UO to determine renal perfusion
Note: septic shock presents initially as decrease in UO
o Clinical Pearls:
Septic shock: vasodilation is the cause of the decrease in bp
MAP of 65 mm Hg is required to maintain perfusion to vital organs
MAP = [2(diastolic pressure) + (systolic pressure)]/3
Sun-burn like rash (desquamation) pathognomonic for S. aureus
Case 6: Labor
o Stages of Labor
Stage 1: (Latent) begging of uterine contractions and cervical ripening;
cervical dilation < 4cm (upper limit for latent phase is 14 hours). (Active)
Cervical dilation from 4-10 cm
Stage 2: Delivery of the fetus
Stage 3: Delivery of the placenta (should occur within 30 minutes of the
fetal delivery)
Stage 4: time after the delivery of the placenta
o Clinical Pearls:
Labor: cervical change accompanied by uterine contractions
Protraction of the active phase: dilation of the cervix that is less than
expected
Nulliparous (normal) 1.2 cm
Multiparous (normal) 1.5 cm
Arrest of the active phase: no cervical dilation in 2 hours
Fetal hear rate variability:
Decelerations: three types: early, variable, and late
Accelerations: 15 bpm lasting at least 15 seconds
Earl Decelerations: occurs at the same time as the contraction and is
gradual. Benign caused by fetal head compression
Variable Deceleration: abrupt change in deceleration and return to baseline.
(not a smooth change). Caused by cord compression
Late Deceleration: occurs after the contraction peak started
Abnormal labor the three Ps should be observed. Fetal hypoxia
(uteroplacental insufficiency) and if persistent fetal acidemia
Power, passenger, and pelvis
Power assessment of uterine contractions (2 ways)
ObGyn Case Files 4
o Clinical: occurring every two to three minutes, firm on
palapation, and last 40-60 seconds
o 10 minute window: measure of mm Hg of contraction
above baseline = Montevideo unit 200 is sufficient
o If not sufficient give oxytocin
Fetal heart rate baseline 110-160 bpm
Fetal tachycardia: variety of reasons (i.e. maternal fever)
Fetal bradycardia: cord compression (most common)
Cesarean delivery
Cephalopelvic disproportion
Arrest of the active phase with adequate uterine contractions
Case 7: Threatened abortion
o Clinical Presentation:
First trimester
Vaginal spotting
Lower abdominal pain
-hCG < 1500 2000 mIU/mL (discriminatory threshold for US)
o Workup:
Page 74, Figure 7-1
Check -hCG
1500 2000 mIU/mL do US
o IUP observed -> monitor closely
o No IUP consider laproscope
1500 2000 mIU/mL repeat level in 48 hours
o Normal rise 66% proabable normal IUP monitor closely
o Abnormal rise 66% non viable pregnancy
D and C
Positive chorionic villi -.> misscariage
Negate villi -> ectopic pregnancy
Treatment:
Ectopic pregnancy
o Medical: Intramuscular methotrexate (side effects lower
abdominal pain); asymptomatic and < 3.5 cm
o Surgical: laproscope
Non- viable pregnancy
o Surgical: D and C
o Medical: vaginal misoprostol
If patient presents with vaginal spotting, severe adnexal pain, and
hypotenstion -> laproscope is warranted
Case 8: Placenta Accreta
o Clinical Presentation:
Abnormally retained uterus -> indicative of placenta accreta
Previous history of c-section, or myomectomy
No cleavage plane of the placenta
o Workup:
Complication: uterine inversion
o Treatment:
Abdominal hysterectomy because the risk of hemorrhage
o Clinical Pearls:
Placenta accreta: placenta adheres to the endometrium and lacks decidual
layer
Placenta increta: placenta adheres to the myometrium
Placenta percreta: placenta adheres to through the myometrium and
penetrates to the serosa
ObGyn Case Files 5
Increase risk of placenta accreta with concurrent placenta previa
Case 9: Gonococcal Cervicitis
o Differential diagnosis:
Ectopic pregnancy (ruled out with negative pregnancy test)
Threatened abortion (ruled out with negative pregnancy test)
Upper genital tract disease (no lower abdominal pain)
o Clinical Presentation:
Vaginal discharge
Post-coital bleeding from endocervix infection
o Workup:
Rule out pregnancy
Diagnosis by gram stain and PCR
N. gonorrhea: one dose ceftriaxone
C. trachomatis one dose azithromycin or 7 days doxycycline
Council patient on STD transmission
o Clinical Pearls:
Gonorrhea is the most common cause of septic arthritis in young women
Most common cause of cervicitis/salpingitis ->Chlamydia, followed by
gonorrhea
Vaginitis with fishy odor discharge: bacterial vaginosis
Sexually transmitted pharyngitis -> gonorrhea (Chlamydia does not cause
pharyngitis)
N. gonnorhea infection: cervicitis, septic arthritis, skin pustular eruptions
Gram negative diplococci -> N. gonorrhea
Chlamydia and gonorrhea frequently coinfect
Infant blindness
Few hours after birth: chemical
2-3 days old: Gonorrhea infection
4-7 days old: Chlamydia infection
Case 10: Complete Abortion
o Clinical Presentation:
Less than 20 weeks gestation
Abdominal pain, vaginal spotting
Passage of fetal tissue (looks like a liver)
Closed cervix
o Workup:
Monitor hCG levels to see that they are halved every 48-72 hours
If not D and C is recommended
o Clinical Pearls:
Threatened abortion: before 20 weeks gestation, vaginal spotting, and
without cervical dilation
Inevitable abortion: before 20 weeks gestation, vaginal spotting, and
cervical dilation, no passage of fetal tissue yet
Incomplete abortion: before 20 weeks gestation, vaginal spotting,
abdominal pain, passage of some fetal tissue, and the cervix remains
open with uterine contractions
Tx: D and C
Completed abortion: before 20 weeks gestation, expulsion of all of the fetal
tissue, and the cervix is closed
Miss abortion: before 20 weeks gestation fetal demise without symptoms of
bleeding or cramping
Differentiation between inevitable abortion and incompetent cervix is +/-
uterine contractions respectively
Page 98
ObGyn Case Files 6
Molar pregnancy: vaginal spotting, absence of fetal heart tones, Fundal
size greater than gestational dates. Diagnosis is made by sonography
Case 11: Shoulder dystocia
o Risk Factors:
Fetal macrosomia, maternal obesity, prolonged second stage of labor, and
gestational diabetes
o Clinical Presentation:
Delivery of the head with retraction against the itroitus turtle sign
o Treatment:
McRoberts maneuver: placing the mothers legs against the chest ->
increases the anterior rotation of the pubic symphysis
Suprapubic pressure: displaces the fetal shoulder axis from anterior-
posterior to oblique
Woods corkscrew maneuver: progressively rotating the posterior shoulder
180 degrees
Delivery of the posterior arm: decreases the fetal bony diameter from the
shoulder to the axilla
Zavanelli maneuver: shove the head back in and deliver by CS
o Clinical Pearls:
Shoulder dystocia: delivery of the head with an inability of the fetal
shoulders to deliver spontaneously
ERB palsy: brachial plexus injury from shoulder dystocia -> waiters tip
position
Maternal complication of postpartum hemorrhage
Fundal pressure is CONTRAINDICATED!!!!
Case 12: Ureteral injury post hysterectomy
o Clinical Presentation:
Post-op from TAH/BSO presenting with fever and flank pain
o Workup:
Intravenous pyelogram
CT scan with contrast of the abdomen
o Treatment:
IV antibiotics and the placement of a ureter stent (via cystoscopy or
percutaneous nephrostomy: placement of the stent through the skin guided
by radiology)
o Clinical Pearls:
Cardinal ligaments:
Connect the cervix to the posterior abdominal wall
Contain the uterine arteries -> which pass of the ureter and is a
possible site for ureter injury in TAH
Infundibular pelvic ligament:
Contains the ovarian artery -> injure the pelvic brim of the renal
collecting system
Bladder lacerations
Top: suture up and good to go
Lower segment (trigone area): may require ureter stent
Meticulous dissection of the uterine aretery can lad to uterter ischemia
Vesicovaginal fistula: leakage from the vagina
Case 13: Postmenopausal Bleeding
o Differential diagnosis:
Endometrial cancer
Atrophic endometrium/vagina
Endometrial polyp
o Clinical Presentation:
ObGyn Case Files 7
Post-menopausal bleeding
o Workup:
Endometrial biopsy followed by
Hysteroscopy
Transvaginal ultrasound
Endometrial strip greater than 5 mm is abnormal in
postmenopausal bleeding
o Treatment:
Surgical therapy TAH
o Risk Factors:
Obesity, diabetes, HTN, prior anovulation (irregular menses), late
menopause, and nulliparity, PCOS, unapposed estrogen exposure with no
progesterone
o Clinical Pearls:
Endometrial polyps: growth of endometrial glands and stroma, which
projects into the uterine cavity
Atrophic endometrium: most common cause of post-menopausal bleeding
Postmenopausal bleeding is endometrial carcinoma until proven otherwise
Surgically staged
Endometrial carcincoma are the most common gyn. Malignancy
Presentation in an atypical patient (without risk factors) tends to be a more
aggressive disease
Case 14: Placenta Previa
o Differential diagnosis:
Placenta previa: placenta lies near or covers the internal os
Complete: covers the entire internal os
Incomplete: covers part of the internal as
Marginal: covers up to the internal as border
Low-lying: not near the internal os, but is located low in the pelvis
Placenta abruption
Separation of the normally implanted placenta
Vasa previa
Umbilical cord vessels insert into the membranes with the vessels
overlying the internal cervical os -> being vulnerable to fetal
exsanguination
o Clinical Presentation:
Painless third trimester bleeding (antepartum bleeding: bleeding after 20
weeks gestation)
o Workup:
Ultrasound -> speculum examination -> digital examination
o Treatment:
ABC of Mom, if hemodynamically stable wait til further in gestation to
deliver
CS delivery at 36-38 weeks
o Clinical Pearls:
Placenta previa, unlike placenta abruption, rarely leads to coagulopathy
Risk Factors for placenta previa
Grand multiparity, prior CS, prior uterine curretage, previous
placenta previa, multiple gestation
A low lying/marginal placenta in the early second trimester should be
monitored, but is of no concern because it should migrate superior as the
uterus grows
Placenta previa increases the risk of placenta acreta
Case 15: Placental Abruption
ObGyn Case Files 8
o Differential diagnosis:
See Case 14 placenta previa
o Clinical Presentation:
Painful antepartum bleeding
o Workup:
Serial Hb levels, fundal height, assessment of FHR
Kleihauer-Best Test: differentiates between maternal and fetal blood by the
addition of the acid. Is based of the solubility of maternal and fetal Hb
o Treatment:
ABC of Mom
If stable: expectant management
Unstable: delivery (CS preferred)
o Clinical Pearls:
Risk Factors: HTN, cocaine, short umbilical cord, trauma, uteroplacental
insufficiency, submucous leiomyomata, sudden uterine decompression,
smoking, Preterm PROM
Concealed abruption: when the bleeding occurs behind the placenta
Fetamaternal hemorrhage: fetal blood enters maternal circulation ->
isoimmunization
Couvelaire uterus: bleeding into the myometrium of the uterus giving s
discolored appearance to the uterus
US is not helpful in the diagnosis
Comlications:
Uterine atony -> postpartum hemorrhage
Coagulopathy: hypofibrinogenemia (below 100-150 mg/dL)
Post-partum: HTN and Preeclampsia
Case 16: Cervical Cancer
o Clinical Presentation:
Abnormal vaginal bleeding, postcoital spotting, and malodorous discharge
(necrotic tumor)
Pelvic examination -> observed lesion
Advance disease: ureter obstruction and spread to the uterosacral/cardinal
ligaments
o Workup:
Screening test: Pap smear
Abnormal Pap: colposcopy with biopsies
Cervical carcinoma: cervical biopsy of the lesion (not a Pap smear)
o Treatment:
Early cervical carcinoma: radical hysterectomy (hysterectomy, removal of
cardinal and uterosacral ligaments, and removal of the vaginal cuff)
Advanced cervical carcinoma: radiation (brachytherapy: radioactive
implants near the tumor bed; teletherapy: external beam of radiation)
Prevention: HPV vaccine -> serotypes 16, 18, 6, and 11
o Clinical Pearls:
CIN: pre-invasive lesions the cervix with cellular atypia
Cervical carcinoma risk factors: early age of coitus, STD, early childbearing,
HPV, smoking, multiple sexual partners
Most common site for lesions to arise is the squamocolumnar junction
Cervical carcinoma spread: cervix -> cardinal ligaments and pelvic walls
Colposcopy guided biopsy stains:
Acetic acid: ppt cellular proteins changing the atypical cells white
Lugols iodine: stains normal cells with high glycogen
o Pap Smear:
ObGyn Case Files 9
Screening test started 3 years after onset of sexual activity or by age 21 ->
annular pap until age 30
After 3 consecutive negatives at 30 may screen every 2-3 years
Hysterectomy with no history of cervical dysplasia no longer require Pap
Hysterectomy with a history of cervical dysplasia requires Pap of the
vaginal cuff
After 65 yo with NO history of cervical dysplasia no longer require Pap
smear
Cytology
ASCUS, LSIL, HSIL
AGUS
Case 17: Sheehan Syndrome (post-partum amenorrhea)
o Differential diagnosis:
Post-partum amenorrhea
Pregnancy (negative pregnancy test)
Sheehan syndrome (anterior hypopituitarism: hypoprolactinemia,
hypothyroidism,
Asherman syndrome (intrauterine adhesions)
o Follows D and C -> scarred endometrium
Amenorrhea
PCOS: estrogen excess without progesterone, obesity, hirsutism,
and glucose intolerance
Hypoestrogen
o Hypothalamic/pituitary dysfunction (low FSH)
o Ovarian failure (elevated FSH)
o Clinical Presentation:
Post-partum hemorrhage
Post-partum amenorrhea with evidence of anterior hypopituitarism
(inability to breast feed)
o Workup:
Pregnancy test if negative
Evaluate pituitary function
Sheehan syndrome
o Anterior hypopituitarism
o Will respond to OCP
Asherman syndrome
o Normally functioning ant. pituitary
o Will not respond to OCP
o Treatment:
Sheehan syndrome: replacement of hormones (T4, cortisol,
mineralocorticoids) and OCP
Asherman syndrome: hysteroscopic resection of scar tissue
Case 18: Fetal Bradycardia (cord prolapse)
o Differential diagnosis:
Cord prolapse
Uterine rupture with prior CS
o Clinical Presentation:
Fetal bradycardia after artificial rupture of membranes
PE of the vagina demonstrates cord
Trendelenburg position
o Workup:
PE of the vaginal vault
Confirm fetal heart rate (fetal scalp electrode or US)
Improve maternal oxygenation and CO
ObGyn Case Files 10
Position changes
Oxygen
IV fluids/pressors: ephedrine (hypotension from epidural)
Discontinue oxytocin
o Treatment:
Push the presenting part superior in the vagina to relieve pressure on the
cord
CS
o Clinical Pearls:
Risk factors for cord prolapse
Artificial rupture of membrane with unengaged fetal part
Transverse fetal lie
Footling breech
Engagement: The fetal part has passed the bony pelvic inlet
Variability
Increase in FHR 6-25 bpm for15 seconds (moderate)
Indicative of good fetal oxygenation
Absence of can be due to sedatives or fetal acidosis
Decelerations -> Case 6
Case 19: Galactorrhea Due to Hypothyroidism
o Differential diagnosis:
Primary hypothryoidism (TRH may act as a prolactin releasing hormone)
Pituitary adenoma (bilateral hemianopsia and headaches)
Pregnancy (positive pregnancy test)
Chest wall trauma
Hypothalamic dysfunction
o Clinical Presentation:
Galactorrhea, oligo/amenorrhea
Nipple discharge will be have fat droplets
o Workup:
History and Physical for possible drug reactions
Pregnancy test
Serum levels of prolactin and TRH, TSH, thyroxine
o Treatment:
Hypothyroidism- > thyroxine hormone supplementation
Pituitary adenoma -> transphenoid microsurgery
Medical
Bromocriptine/cabergolamine: dopamine agonist
o Clinical Pearls:
Hyperprolactinemia inhibits the pulsing of GnRH, which inhibits the cyclic
releaes of FSH and LH resulting in the amenorrhea and galactorrhea. Lack
of FSH and LH cycling leads to hypoestrogen -> osteoporosis
Galactorrhea with normal menses indicates that the hypothalamus is
function normally and can rule out hypothalamic dysfunction
MRI is the most sensitive imaging test for pituitary adenoma
Case 20: Pruiritus (Cholestasis) of Pregnancy
o Differential diagnosis:
Cholestasis of pregnancy
Systemic itching and lack of a rash
Pruritic Urcticarial paupules of pregnancy:
Erythematous papules with a white halo and hives that start on the
abdomen and spread to the buttocks
Histology shows lymphocytic and histiocyte invasion, but is ne
Herpes gestationis
ObGyn Case Files 11
NOT associated with HSV
Intense itching and vesicles on the abdomen and extremities
Diagnosis confirmed by IF positive for IgG+C3 in the BM
o Clinical Presentation:
Systemic itching +/- jaundice
No elevation of liver enzymes (important to differentiate it from hepatitis
which will have elevated liver enzymes)
o Workup:
Serum bile acid levels
Liver enzymes
o Treatment:
Cholestasis of pregnancy -> antihistamines, cornstarch bath,
ursodeoxycholic acid (increase secretion of bile acids)
Pruritic Urcticarial paupules of pregnancy (PUPP) -> topical steroids and
antihistamines
Herpes gestationis -> ORAL steroids
o Clinical Pearls:
INTRAHEPATIC cholestasis of pregnancy
If associated with jaundice has an increase incidence of
prematurity, fetal distress and fetal loss
Herpes Gestationis
NOT related to HSV
Maternal development of anti-BM IgG which leads to deposition of
IgG + C3 in the BM causing vesicles
Case 21: Salpingitis, Acute
o Differential diagnosis:
Pyelonephritis, appendicitis, cholecystitis, diverticulitis, pancreatitis,
ovarian torsion, and gastroenteritis
o Clinical Presentation:
Cervical motion tenderness, abdominal tenderness, adnexal tenderness
o Workup:
Clinical diagnosis; see clinical presentation
Pregnancy test
Chlamydia and gonorrhea test
US for TOA
Laparoscope is the gold standard for diagnosing PID
o Treatment:
Inpatient: cefotetan and doxycycline
If it does not resolve in 48-72 hours laparoscope
o Clinical Pearls:
PID: synonymous with acute salpingitis
Cervical motion tenderness: tell tale sign of salpingitis
Tubo-ovarian abscess: collection of purulent material around the distal tube
and ovary; usually treated with by antibiotic therapy before drainage
Acute salpingitis with RUQ pain is indicative of Fitz-Hugh-Curtis syndrome
Etiology: Chlamydia, gonorrhea, and polymicrobial
IUD increases risk of PID
OCP decreases risk of PID
Long term sequelae: chronic pelvic pain, ectopic pregnancy, involuntary
infertility
Case 22: Pulmonary Embolus of Pregnancy
o Differential diagnosis:
Reactive airway disease, pneumonia, pulmonary embolis
o Clinical Presentation:
ObGyn Case Files 12
Dyspnea, acute onset, pleuritic chest pain, lungs: CTAB, hypoxemia, clear
chest x-ray
o Workup:
Page 192; Figure 22-1
Pulse oximetry and arterial blood gas
Diagnosis of PE is made by a spiral CT, MRI angiography,
o Treatment:
IV heparin 5-7 days and then switched to subq heparin to maintain an aPTT
at 1.5-2.5x control for three months
o Clinical Pearls:
Etiology: hypercoagulable state of pregnancy -> high estrogen and
mechanical effect of venous stasis
Other etiologies: Protein C and S resistance, antithrombin III
activity, Factor V Lieden mutation, hyperhomocysteinememia,
antiphospholipid syndrome
Dyspnea: most common symptom of PE, tachypnea: most common sign of
PE
Asthma: initially hyperventilation and decrease in PCO2 as the patient
begins to weaken PCO2 increases
Page 193; Table 22-1
Case 23: HSV infection in Labor
o Clinical Presentation:
Prodrome: tingling, burning, or itching of the perineal region,
o Workup:
Acyclovir
Primary infection: reduces viral shedding, pain symptoms, and
faster healing
Prophylaxis: decrease symptoms and the need for a CS
o Treatment:
Absence of herpetic lesions or prodrome symptoms -> patient opt for a
vaginal delivery
Presence of herpetic lesions of prodrome symptoms -> CS
o Clinical Pearls:
Neonatal HSV:
Majority occurs through exposure of fluids during birth
It can be systemic or localized
5-10% may become infected transplacentally, but this usually
occurs during the primary infection
Syphilis: 1
st
stage small, round painless chancre
Chancroid: H. ducreyi painful genitial lesions
Bartholin glands: painless abscesses at the entrance of the vagina
Vulvar carcinoma: nontender, ulcerative, and more common in post-
menopausal women
Case 24: Uterine Leiomyomata
o Differential Diagnosis
Ovarian mass: lateral position
Endometrial hyperplasia, polyp or uterine cancer: metrorrhagia
Pelvic kidney, TOA, endometrioma
o Clinical Presentation:
Menorrhagia, enlarged midline mass that is irregular, and contiguous with
the cervix
o Treatment:
OCP and NSAIDS
GnRH agonists (most effective in first three months for shrinking the fibroid
ObGyn Case Files 13
Uterine artery embolization or myomectomy -> attempt to preserve fertility
Definitive treatment is hysterectomy
o Clinical Pearls:
Carneous (red) degeneration: changes of the leiomyomata due to rapid
growth; the center becomes red, causing pain
Most common tumor of the female pelvis and is leading indication for
hysterectomy
Submucosal fibroids and the most likely associated with recurrent
abortions -> difficulty with fertility and embryo implantation
Leiomyosarcoma is differentiated from lieomyoma based on different
growth rates
Case 25: Preeclampsia and Hepatic Rupture
o Clinical Presentation:
Preeclampsia with severe onset of epigastric pain, abdominal distension,
syncope, hypotension, and tachycardia
o Workup:
Labs: CBC, urinalysis, 24 hours protein collection, CMP, LDH, and uric acid
test
Fetal testing : BPP
o Treatment:
Page 219; Figure 25-1
Delivery of the fetus
MgSO4: seizure prevention
HTN: postpartum treated with hydralazine or labetalol
o Clinical Pearls:
Chronic HTN: BP 140/90 before 20 wks gestation
Gestational HTN: BP 140/90 after 20 wks gestation
Preeclampsia: HTN, proteinuria > 300 mg in 24 hours, and edema at a
gestational age greater than 20 wks due to vasospasm (mild BP 140-
160/90-110)
Eclampsia: preeclampsia + seizures
Severe preeclampsia: BP >160/110 (can be systolic, diastolic or both),
proteinuria > 5g in 24 hours or urine dipstick with 3+ or 4+ proteinuria
Superimposed preeclampsia: preeslampsia in a patient with chronic HTN
Complications of preeclampsia are: placental abruption, eclampsia,
coagulopathies, hepatic rupture, hepatic capsular hematoma, and
uteroplacental insufficiency
MgSO4 toxicity:
Case 26: Fibroadenoma of the Breast
o Differential diagnosis:
Fibroadenoma: benign, smooth muscle tumor of the breast; most common
breast mass; does NOT respond to hormones
Fibrocystic changes: lumpy-bumpy breast; most common benign breast
condition; lobules become swollen and cystic that become fibrotic
CP: cyclic, painful, engorged breast right before mestruation
Tx: decrease caffeine, NSAIDS, proper bra, OCP and oral progestin
o Clinical Presentation:
Firm, nontender, rubbery mass
o Workup:
Core needle biopsy: 14-16 gauge needle used to extract tissue and
preserves cellular architecture
Fine needle aspiration: small gauge needle with associated vacuum to
aspirate fluid and cells from a breast mass or cyst, does not preserve
cellular architecture
ObGyn Case Files 14
Triple assessment: clinical examination, US/Mammogram, and histology
(less than 35 may use FNA b/c less likely to be malignant cancer
o Treatment:
Small mass and not growing may choose to leave alone, but most women
opt for lumpectomy
Over the age of 35, + Family Hx, or discordinant triple assessment warrants
further investigation: (excisional biopsy or core needle biopsy)
Case 27: Infertility, Peritoneal Factor
o Differential diagnosis:
Five basic factors of infertility: ovulatory, uterine, tubal, male factor, and
peritoneal factor (endometriosi/cervical factor)
o Clinical Presentation:
Infertility: inability to conceive after 1 year of unprotected intercourse
Primary never been able to get pregnancy
Secondary has a past history of pregnancy
o Workup:
Ovulatory:
Basal body temperature looking for a biphasic profile -> rise occurs
after ovulation and is due to progesterone
Urine LH kit
Progesterone levels
Uterine problem: hysterosalpingogram (more common with recurrent
pregnancy loss not infertility)
Tubal problem: hysterosalpingogram; laparoscope which is the gold
standard for diagnosis
Male factor problems: semen analysis
Peritoneal factor: laparoscope gold standard for diagnosis
Cervical factor: too thick cervical mucous for the sperm to get to the egg,
rare, treated with intrauterine insemination
o Treatment:
Surgery is the main treatment for tubal abnormalities or endometriosis
o Clinical Pearls:
Endometriosis: three Ds: dysmenorrhea, dyspareunia, and dyschezia
Fecundability: probability of achieving a pregnancy within one mestrual
cycle
Case 28: Abdominal Pain in Pregnancy (Ovarian Torsion)
o Differential diagnosis:
Page 238; Table 28-1
o Clinical Presentation:
More common at 14 wks gestation (uterus clears pelvic brim) or
postpartum
Acuter onset unilateral abdominal or pelvic pain
Nausea and vomiting
NO fever, NO leucocytosis
o Workup:
Usually differentiated based on history and physical exam
o Treatment:
Surgical intervention
Necrotic: removal of the ovary
Ischemia: release the torsion -> untwist the pedicle
o Clinical Pearls:
Ovarian torsion: is the most frequent and serious complication of a benign
ovarian cyst;
Case 29: Ectopic Pregnancy
ObGyn Case Files 15
o Differential diagnosis:
Page 248; Table 29-2
o Clinical Presentation:
Amenorrhea, vaginal spotting, abdominal pain, no intrauterine pregnancy
(IUP) observed
o Workup:
hCG levels:
>66% rise in 48 hours is indicative of a viable (IUP)
<66% rise in 48 hours is indicative of abnormal pregnancy (i.e.
ectopic)
Progesterone
>25 ng/mL indicative of IUP
<5 ng/mL indicative of an abnormal pregnancy
US
Crown-rump length or yolk sac -> + IUP
Gestational sac is not a definitive measure of the presence of an IUP
because an ectopic can produce a pseudogestational sac
If no IUP is detected laparoscope is indicated for definitive diagnosis
o Treatment:
Surgical
Preserve fertility: salpingostomy
Do not wish to preserve fertility: salpingectomy
Medical
Pregnancy less than 4 cm methotrexate
o Clinical Pearls:
Plateau in hCG levels after 8 wks is indicative of miscarriage or ectopic
Case 30: Anemia of Pregnancy (thalassemia)
o Differential diagnosis:
Iron deficiency anemia: increase in demand
Beta thalassemia
o Clinical Presentation:
Microcytic anemia with normal iron levels and ferritin
Elevated Hb A2 on electrophoresis
NOTE: Elevated HbF indicative of alpha thalassemia
o Workup:
CBC, Iron, Ferritin levels, Hb electrophoresis
o Treatment:
Fe deficiency anemia: treatment with Fe for 3 - 4 weeks
Beta thalassemia minor: no treatment indicated, monitor
o Clinical Pearls:
Most common cause of megaloblastic anemia in pregnancy is folate
deficiency
G6PD: hemolytic anemia following reducing drugs (sulfonamides,
nitrofurantoin, and antimalarial)
NOTE: nitrofurantoin is a common drug used to treat UTI in
pregnancy


Case 31: Preterm Labor
o Clinical Presentation:
Contractions with cervical change between the weeks 20-37
o Workup:
Page 266 Table 31-2
Fetal fibronectin: + may or may not be preterm labor preterm labor
ObGyn Case Files 16
If in preterm labor: begin tocolysis, steroids (weeks 24-34), GBS
prophylaxis (penicillin)
Cervical length assessment: TVUS -> less than 25 mm increase risk in
preterm labor
Weekly injections of 17-hydroxyprogesterone caproate from weeks 20 36
to prevent preterm
o Clinical Pearls:
Tocolytic agents: Page 267 Table 31-3
Gonococcal cervicitis strongly associated with preterm labor (Chlamydia is
not)
Dyspnea on tocolysis is usually due to pulmonary edema

Case 32: Bacterial Cystitis
o Differential diagnosis:
Bacterial cystitis (E. coli), cervicitis (gonorrhea, chlamydia; no growth on
the urine culture), candidal vaginitis, and urethral syndrome (urgency and
dysuria caused by inflammation; urine cultures are negative)
o Clinical Presentation:
Dysuria, frequency, urgency
o Workup:
UA and Urine culture
Acute pyelonephritis: in pregnancy after treatment standard of care is
antibiotic prophylaxis to term
o Clinical Pearls:
Pyelonephritis: UTI symptoms + flank tenderness and fever
Asymptomatic bacturia has a high incidence in women with sickle cell trait
Case 33: Contraception
o Clinical Pearls:
Emergency contraception:
Yuzpe method: two high doses of the combination pill within 72
hours
o High incidence of N/V
Plan B: two high doses of progesterone within 72 hours
Copper IUD within 5 days
OCP: decrease risk of endometrial and ovarian cancer
Contraceptive patch has an increase risk of DVT
35 yo and smoker is a contraindication for OCP
Pages 283-285 Table 33-2
Case 34: Pyelonephritis, Unresponsive
o Clinical Presentation:
Acute pyelonephritis: UTI symptoms plus flank pain and fever
48 to 72 hours after the administration of antibiotics (cephalosporin or
ampicillin and gentamicin) there is not response -> high risk for
progression to ARDS
Consider ureterolithiasis or perinephric abscess
ARDS alveolar and endothelial damage leading to leaky pulmonary
capillaries caused by endotoxins, clinically causing hypoxemia, large
alveolar-arterial gradient, and loss of lung volume (dyspnea and tachypnea)
Temporary increase in creatinine and liver enzymes
o Treatment:
ARDS: oxygenation and fluid management in severe cases mechanical
ventilation
o Clinical Pearls:
Most common cause of sepsis in pregnant women is pyelonephritis
ObGyn Case Files 17
Pregnancy with a case of acute pyelonephritis post treatment has to be
treated with antibiotic prophylaxis for the rest of the pregnancy
Case 35: DVT in Pregnancy
o Clinical Presentation:
Calf pain (deep linear cords), leg edema, increase in leg size
o Workup:
Doppler flow (pregnant) and venography (not pregnant)
o Treatment:
Bed rest and extremity elevation
Heparin
IV for 5-7 days, followed by oral heparin to reach therapeutic
dosing for three months, and then heparin prophylaxis until 6 wks
post partum
MOA: stabilizes antithrombin and prevents clot propogation
Complications: osteoporosis and thrombocytopenia
o Clinical Pearls:
Risk of DVT increases in pregnancy because of hypercoagulable state
(increase in clotting factors particularly fibrinogen) and mechanical stasis
induced from the gravida uterus
DVT complication is pulmonary embolism
Case 36: Dominant Breast Mass
o Clinical Presentation:
Mobile, non-tender mass
o Workup:
Mammography, US, FNA (less than 35), excisional biopsy/core needle
biopsy (greater than 35)
o Treatment:
o Clinical Pearls:
Age is the most important risk factor for breast cancer
Invasion of lymph nodes is the most important factor for prognosis
BRCA1 chromosome 17 mutation; BRCA2 chromosome 13 mutation;
autosomal dominant inheritance
Genetic testing for BRCA1/2 is required for two first degree relatives with
breast cancer
3D breast mass, must be biopsied irregardless of imaging results
When to get a mammogram
20-39: every 3 years
40-49: every 2 years and yearly breast exam
50+: annual breast exam
Most common cause of serosenguinous nipple discharge from a single duct
is intraductal papilloma
Infiltrating intraductal carcinoma is the most common histological type
Case 37: Ovarian Tumor (Struma Ovarii)
o Differential diagnosis:
Benign or Malignant; gonadal, stromal, or epithelial ovarian tumors
o Clinical Presentation:
Complex cystic tumor, unilateral (multilobulated with thick setpae)
Symptoms of hyperthyroidism, but a normal physical exam for the thyroid
o Workup:
TVUS of the cyst to evaluate the mass and laparotomy with ovarian
cystectomy
o Germ Cell Tumors:
Most common is a benign cystic teratoma (dermoid cyst)
ObGyn Case Files 18
The most common tissue type is squamos, but the dermoid can
contain all three germ layers
Complications: torsion of the ovary or rupture (rare)
Immature teratoma/malignant teratoma
Contains all three germ layers and the amount immature neural
elements determines the grade
Grade I: treat with salpingoophrectomy
Grade II-III: salpingoophrectomy and chemotherapy
o Epithelial Tumors:
Serous: psammoma bodies; most common; bilateral
Mucinous: unilateral; large; may rupture and lead to pseudomyxoma
peritoneii
Endometroid: presence of endometrial glands
Elevated CA125, but is nonspecific in reproductive women
o Stromal tumor:
Granulosa theca cell tumor: solid and secretes estrogen
Sertoli-leydig cell tumor: solid and secretes androgens
o Functional Cysts:
Follicular, corpus luteal, and thecal-lutein
o Clinical Pearls:
The presence of ascites on US is indicative of a malignant process
Page 316 Table 37-3
Ovarian cancer staging: TAHBSO, lymph nodes, ascites, omentum
Case 38: Fascial Disruption
o Differential diagnosis:
Superficial wound infection, wound dehiscence, fascial disruption,
evisceration
o Clinical Presentation:
Larger volume of a serosanguinous fluid from the abdomen,
Risk factors: vertical incision, obesity, DM,corticosteroid, infection,
increasing intra-abdominal pressure
o Treatment:
Superficial wound infection: surgical drainage of the wound and broad
spectrum antibiotics
Wound Dehiscence: surgical closure and broad spectrum antibiotics
Fascial Disruption: surgical repair and broad spectrum antibiotics
Evisceration: covering the bowel with a moist towel and immediate surgical
repair
o Clinical Pearls:
Wound dehiscence: separation of the surgical incision with peritoneum
remaining intact
Fascial disruption: disruption of the peritoneum and pannus
Evisceration: fascial disruption with protruding bowel
Wound dehiscence risk factors same as fascial disruption
Most common cause of fascial disruption is the suture tearing through the
fascia
Differentiation of lymphatic drainage and urinary tract fistula is evaluation
of the creatine level in the draining fluid from the incision (elevated
creatinine in urine)
Superficial wound infection usually occurs due to infection or hematoma
Case 39: Abdominal Pain In Pregnancy (Ruptured Corpus Luteum)
o Differential diagnosis:
Ectopic pregnancy (most common cause of hemoperitoneum), ruptured
endometrioma, adnexal torsion, appendicitis, splenic injury/rupture
ObGyn Case Files 19
o Clinical Presentation:
Symptoms of hemorrhagic shock (tachycardia, hypotension, syncope) and
hemoperitoneum (abdominal pain, abdominal distension, rebound
tenderness, positive fluid wave)
o Workup:
US demonstrating free fluid in the peritoneum which is confirmed by
laparoscope
o Treatment:
o Clinical Pearls:
Corpus luteal cyst: grow under the influence of hCG and up to weeks 10-12
produce the majority of the progesterone required for pregnancy.
The cyst can have intrafollicular bleeding which may become
excessive leading to rupture and bleeding into the peritoneum
Carneous degeneration of a leiomyoma typically presents with localized
tenderness over the fibroid
The first sign of hypovolemia is decreased urine output
If cystectomy is performed before weeks 10-12 supplemental progesterone
should be given to prevent abortion
Vaginal tissue discharge can be tested for the presence of chorionic villi by
the addition of the tissue to normal saline if the tissue floats in a frond
pattern it is indicative of chorionic villi and supports the diagnosis of an
intrauterine pregnancy
Hemorrhagic corpus luteum usually occurs in women with bleeding
tendencies
Case 40: Secondary Amenorrhea (intrauterine adhesions)
o Differential diagnosis:
Pregnancy, hypothalamic/pituitary dysfunction, ovarian dysfunction
o Clinical Presentation:
Secondary amenorrhea post endometrial trauma (D and C)
o Workup:
Pregnancy test, FSH and LH levels, Estrogen levels, basal body temperature
plot, trial OCP/progesterone withdraw, TSH, prolactin levels
Hysterosalpingogram/hysteroscopy (diagnostic gold standard)
o Treatment:
Surgical hysteroscopy, placement of IUD or pediatric foley catheter to
prevent further adhesions, OCP
o Clinical Pearls:
Intrauterine adhesions (Asherman syndrome) sin qua non is endometrial
trauma, especially to the basalis layer
Myometrial adhesions have a worst prognosis
CP: positive ovulation, normal hypothalamic and pituitary fnx, with cyclic
abdominal cramping post D and C and cone biopsy -> diagnosis: cervical
stenosis preventing passage of products of menstration -> increase
incidence of retrograde mestruation and endometriosis
Case 41: Breast, Abnormal Mammogram
o Case 36: Dominant Breast Mass
o Clinical Pearls:
A history of breast trauma with calcifications in the same area is indicative
of fat necrosis. However, a confirmatory biopsy is still required
Modern mammogram has no increase risk of malignancy
All breast masses or positive mammograms have to be confirmed by biopsy
Case 42: Primary Amenorrhea, Mullerian Agenesis
o Differential diagnosis:
Pregnancy, Turner syndrome (lack breast development), androgen
insensitivity (lack pubic and axillary hair), mullerian agenesis (+ breast
ObGyn Case Files 20
development and pubic/axillary hair; may be positive for renal
abnormalities)
o Clinical Presentation:
Mullerian agenesis: Tanner stage IV for both breast and pubic/axillary hair
development, with renal abnormalities
Androgen insensitivity: Tanner state IV for the breast, but underdeveloped
pubic/axillary hair
o Workup:
Serum testosterone levels and karyotype
o Treatment:
Androgen insensitivity: gonadal dysgenesis -> high risk of malignant
transformation
o Clinical Pearls:
Estrogen: promotes breast development
Sources: ovaries, adrenals, and peripheral conversion
Testosterone: promotes pubic and axillary hair development
Turner syndrome: lack of breast development and gonadal dysgenesis
Kallman syndrome: hypogonadotropic hypogonadism -> deficiency of GnRH
and inability to smell
Case 43: Septic Abortion
o Clinical Presentation:
Post D and C for abortion presenting with fever and leucocytosis
Indications of retained products of conception
Open cervical os, lower abdominal cramping, vaginal bleeding
Cervical motion tenderness and foul smelling discharge
o Workup:
CBC with differential, Urinalysis, and CMP
o Treatment:
Maternal ABC, broad spectrum antibiotic therapy (gentamicin and
clindamycin or metronidazole, ampicillin, and an aminoglycoside), repeat
uterine curretage
o Clinical Pearls:
Septic abortion is caused by an ascending infection
CT scan positive for air pockets in the myometrium -> clostridium infection
-> treatment with hysterectomy to prevent significant morbidity and
mortality
Bacteria polymicrobial: streptococci, bacteroides, GBS, staph
Case 44: Postpartum hemorrhage
o Differential diagnosis:
Uterine atony (most common cause), genital tract lacerations, uterine
inversion, placenta accreta, retained placenta, or coagualopathy
o Clinical Presentation:
PPH (>500mL vaginal and >1000mL CS)
Boggy uterus on palpation
o Treatment:
Maternal ABC
Medical therapy
Begin oxytocin -> methylergevine (contraindicated with HTN)->
PGF2 (contraindicated with asthma) -> rectal misoprostol
Surgical therapy
Ligation of uterine or internal iliac artery
B-lynch stitch
All else fails hysterectomy
o Clinical Pearls:
ObGyn Case Files 21
Treatment for preeclampsia with MgSO4 increases the risk of uterine atony
Late PPH: subinvolution of the placental site occurring 10-14 days
postpartum (hematoma from the placenta falls off and bleeds) -> oral ergot
alkaloids is the standard of care
Risk of uterine atony Page 361 Table 44-1
Case 45: Pubertal Delay, Gonadal dysgenesis
o Differential diagnosis:
Hypogonadotropic
Hypogonadism
o Clinical Presentation:
Delay in puberty (i.e. thelarche -> adrenarche -> growth spurt -> menarche
o Workup:
Measurement of FSH levels
Decreased FSH -> hypogonadotropic
o Eating disorder, XS exercise, cushing syndrome, pituitary
adenomas, and craniopharyngiomas
Elevated FSH -> hypogonadism
Decrease estrogen and FSH -> FSH, prolactin, TSH, free T4, adrenal
and ovarian steroids
o Treatment:
Hormonal therapy (i.e. OCP), HGH, and the prevention of osteoporosis
o Clinical Pearls:
Most common karyotype of gonadal dysgeneisi is 45XO
Delayed puberty is the lack of secondary sexual characteristics by age 14
Primary amenorrhea with normal breast development -> pregnancy test
Case 46: Breast Abscess and Mastitis
o Differential diagnosis:
Mastitis/breast abscess
Galactocele: noninfectious collection of milk in the mammary duct due to
blockage -> nonerythematous fluctuant mass
o Clinical Presentation:
Breast pain, fever, induration, redness
If + for fluctuance -> breast abscess
o Workup:
If physical exam is+ for fluctuance confirm diagnosis with US
o Treatment:
Mastitis -> S. aureus is the most common etiology and should be treated
with dicloxacillin
Breastfeeding should be encouraged to prevent breast abscess
Breast abscess -> surgical drainage and dicloxacillin
o Clinical Pearls:
Breast milk lacks vitamin D and needs to be supplemented at 2 months
Maternal HIV infection is a contraindication to breastfeeding
Best treatment for cracked nipples is air-drying and the avoidance of harsh
soaps
Breast engorgement is due to vascular congestion and milk accumulation ->
Tx: breast binder, ice packs, and analgesia
Note fever will not persist pass 24 hours


Case 47: Thyroid Storm of Pregnancy
o Clinical Presentation:
Symptoms of hyperthyroidism: tachycardia, nevoursness, sweating,
diarrhea
ObGyn Case Files 22
Autonomic instability/change in mental status-> hallmark of thyroid storm
o Treatment:
Propylthiouracil: inhibits peripheral conversion of T4 to T3
Side effects: bone marrow aplasia -> increase risk of sepsis
Methimazole: similar to PTU, but contraindicated in pregnancy
Beta-blocker: to protect the heart
Acetominophen/cooling blankets: treat hyperthermia
Corticosteroids: prevent peripheral conversion of T4 to T3
o Clinical Pearls:
Graves disease is the most common cause of hyperthyroidism in the US ->
treated with PTU
During pregnancy total thyroxine levels increase, but relative levels of
thyroxine are maintained by a corresponding increase in thyroid binding
globulin
Postpartum thyroiditis
Postpartum hyperthyroidism patient is more likely to demonstrate
hypothyroidism after the delivery of the placenta (decrease in
corticosteroids) and rise of anti-microsomal/antiperoxidase
immunoglobulins
Maternal hypothyroidism left untreated can lead to neonatal and childhood
neurodevelopmental delays
Pregnancy thyroid changes
Increase: total T4, TGB
Unchanged: free T4, TSH
Case 48: Chlamydial Cervicitis and HIV in pregnancy
o Chlamydia:
Vertical transmission occurring during L and D causing neonatal
conjunctivitis and pneumonia
Hence, why it is imperative to have a negative Chlamydia screen in
the third trimester
It is not prevented by eye drops of erythromycin prophylaxis ->
however, this does work to prevent gonococcal conjunctivitis
Has a propensity for transitional and columnar epithelium
Diagnosed by IF or PCR
Treatment: amoxicillin for 7 days or one dose azithromycin
Most common cause of conjunctivitis in the first month of life
Because of repeat infection repeat testing is prudent in the third trimester
o HIV:
Vertical transmission can occur via transplacental, during delivery, or
breastfeeding
Primary goal of HART therapy with pregnancy is to decrease the viral load -
> decrease the risk of vertical transmission
Management
Place Mom on HARRT therapy
Scheduled CS
If a vaginal delivery is decided on then IV AZT should be given
during the delivery
Neonate receives oral AZT for 6 months
Most common method of HIV transmission to women in the US is via
heterosexual intercourse
Case 49: Parvovirus Infection in Pregnancy
o Clinical Presentation:
Myalgia, lacy red rash, and low grade fever + exposure to a child with
parvovirus (slapped cheek presentation)
ObGyn Case Files 23
o Workup:
Maternal serology of IgM and IgG antibodies to parvovirus
US for fetal hydroamnios
PUBS to diagnose fetal anemia
o Treatment:
Fetal transfusion
o Clinical Pearls:
Parvovirus is a single stranded DNA virus. Also called fifth disease
Fetal infection leads to suppression of RBC production -> fetal anemia ->
hydroamnios -> hydrops fetalis (high output cardiac failure and third
spacing)
Sinusoidal FHR: FHR pattern is a sine wave every 3-5 minutes and is
indicative of severe anemia/fetal asphyxia
Maternal Serology: Page 395 Table 49-1
Causes of hydroamnios: gestation diabetes, isoimmunization, syphilis, fetal
cardiac arrhythmias, and fetal intestinal atresias
Case 50: Postpartum Endomyometritis
o Differential diagnosis: Postpartum Fever
Atelectasis, pyelonephritis, breast engorgement, wound infection,
endometritis
Endometritis, wound infection, necrotizing fasciitis, and septic pelvic
thrombophlebitis
o Clinical Presentation:
Postpartum fever, fundal tenderness, foul smelling lochia
Usually presents with postpartum fever on day 2
o Treatment:
Broad spectrum antibiotic therapy
Gentamicin and clindamycin
If fever persist past 48 hours of antibiotics add ampicillin to cover
E. coli
If fever persists 48-72 hours post ampicillin CT exam is warranted
to reveal an abscess or infected hematoma
o Clinical Pearls:
Endometritis is caused by the ascension of bacteria into the uterus
Endometritis is a polymicrobial infection with the predominant bacteria
being anaerobic (i.e. bacteroides)
Fever PPD #1 -> necrotizing fasciitis -> debridement and antibiotics to
cover streptococcus
Fever POD #4 -> wound infection -> debridement and antibiotics
Septic pelvic thrombophlebitis: bacterial infection of pelvic venous thrombi,
usually involving the ovarian veins -> bacteria spread from the placental
implantation site -> antibiotics +/- heparin
The most common cause of fever post-CS is endomyometritis
Case 51: Syphillis
o Differential diagnosis:
Syphillis:
Stage 1: painless chancre and adenopathy +/- pain
Stage 2: macular/papular rash of palms and soles and condyloma
lata
Stage 3: cardiovascular abnormalities, neurosyphillis
HSV: painful vesicular lesions with a sequlae of encephalitis/urinary
retention
Chancre: painful chancre with ragged edges and a necrotic base + painful
lymphadenopathy
ObGyn Case Files 24
o Clinical Presentation:
Painless chancre and usually painless adenopathy
o Workup:
RPR or VRDL if negative confirm with dark field microscopy
MHA-TP and FTA-ABS test are used to confirm RPR/VRDL
o Treatment:
Penicillin if allergic desesntize and treat with penicillin
< 1 year treat with one dose IM penicillin
> 1 year treat with three courses of penicillin at 1 week intervals
o Clinical Pearls:
Abrupt increase in RPR titers post treatment is indicative of reinfection
Lumbar puncture can be used to diagnosis neurosyphillis
Case 52: Intra-amniotic Infection
o Clinical Presentation:
PROM, maternal fever, fetal tachycardia, fundal tenderness
First sign of chorioamnionitis is fetal tachycardia
o Workup:
Sterile speculum exam showing pooling of the amniotic fluid in the
posterior vaginal vault
Alkaline changes of the fluid and ferning pattern
US to reveal oligohydroamnios
o Treatment:
Less than 32 weeks antenatal steroids and antibiotics (has been shown to
delay pregnancy up to one week)
After 34-35 wks induction of labor with the addition of antibiotics
(ampicillin/gentamicin) if infection is apparent.
o Clinical Pearls:
Premature rupture of membranes: rupture of membranes before the labor
Complications of PROM: labor, chorioamnionitis, RDS, placental abruption,
and necrotizing entercolitis
Listeria may induce chorioamnionitis without rupture of membranes
GBS and E. coli are the most common organisms to affect neonates
Case 53: Bacterial vaginosis
o Differential diagnosis:
Bacterial vaginosis, Trichomonas, and Candida
o Clinical Pearls:
Page 423 table 53-1
Organism of wet mount prep T. vaginalis
Predominance of anaerobes in bacterial vaginosis
BV and trichomonas are associated with alkaline pH and positive whiff test
Candidal vulvovaginitis infections are common in pregnancy women who
are taking broad spectrum antibiotics, diabetic, or immunosuppressed
BV is associated with preterm labor, post-partum endometritis, and PID
T. vaginalis is associated with an intense inflammatory process and may
induce punctuations of the cervix known as strawberry cervix
Case 54: Hirsutism, Sertoli-Leydig Cell Tumor
o Differential diagnosis:
Cushing syndrome: buffalo hump, HTN, central obesity, straie, diagnosed
with dexamethasone test
Adrenal tumor: abrupt increase in DHEA-S (abrupt presentation of
hirsutism); virilization
Adrenal hyperplasia: hirsutism, virilization, and anovulation; elevated
morning fasting 17-hydroxyprogesterone
ObGyn Case Files 25
PCOS: elevated testosterone, but is a slow increase in testosterone so the
process of hirsutism is over a period of years, patient is also obese with
anovulatory cycles
Sertoli-Leydig cell tumor: abrupt onset of hirsutism and virilization with an
ovarian mass
Page 432 Table 54-1
o Clinical Presentation:
Abrupt onset of hirsutism and virilization with an ovarian mass
o Workup:
Based of the H and P
Labs: DHEA-S, testosterone, 17-hydroxyprogesterone, prolactin, and TSH
o Treatment:
Sertoi-Leydig cell tumor: surgical excision
o Clinical Pearls:
Abrupt growth of hirstusim is indicative of a ovarian or adrenal androgen
secreting tumor and slow growth of hirsutism is indicative of PCOS
The most common cause of hirsutism and irregular menses is PCOS
Case 55: Serum Screening in pregnancy
o Clinical Pearls:
At 16 weeks the fundus of the uterus should be at the levele between the
pubic symphysis and the umbilicus
At 20 weeks the fundus should be at the level of the umbilicus
Triple screen weeks 15-21
Elevated msAFP -> indicative of neural tube defect
Low msAFP and estradiol with an elevated hCG -> indicative of
Downs syndrome
Low msAFP, estradiol, and hCG -> indicative of trisomy 18
First trimester screen for Downs syndrome
Low PAPP-A and beta hCG with thickened nuchal translucency ->
Downs syndrome
The genetics for a cleft palate/lip only are multifactorial
Unexplained elevation of msAFP has an increase risk for still brith
Most common cause of abnormal triple screen is wrong dates
95% of neural tube defects are determined by targeted US
Case 56: PCOS
o Differential diagnosis:
See Case 54
o Clinical Presentation
Long-standing history of irregular cycles, obesity, hirsutism, and acne
o Workup:
DHEA-S, 17-hydroxyprogesterone, testosterone, prolactin, TSH
Endometrial biopsy
Glucose tolerance test
PCOS diagnosis is one of exclusion
o Treatment:
OCP: to regulate cycles and decrease unopposed estrogen exposure
Diet and Exercise: reduce hyperinsulinemia and hyperandrogenism
Clomiphene citrate: to induce ovulation if pregnancy desired
o Clinical Pearls:
PCOS patients are at an increase risk of developing metabolic syndrome:
DM, cardiovascular disease, hyperlipidemia, HTN
Stage I endometrial carcinoma and a desire to maintain fertility treat with
high dose progesterone
ObGyn Case Files 26
Testosterone largely secreted by the ovary and DHEA-S is largely secreted
by the adrenal gland
Case 57: Pelvic Organ Prolapse
o Differential diagnosis:
Cystocele: Defect in the pelvic muscular support of the bladder -> anterior
pelvic organ prolapse
Enterocele: Defect in the pelvic muscular support of the uterus and cervix
or vaginal cuff -> central pelvic organ prolapse
Rectocele: Defect in the pelvic muscular support of the rectum allowing
feces to impinge on the vagina -> difficulty having BM -> posterior pelvic
organ prolapse -> Tx posterior repair (colporrhaphy)
Paravaginal defect: defect in levator ani attachments to the lateral pelvic
walls -> vaginal prolapse
o Clinical Presentation:
Feeling as if something is falling out of the vagina.
Past medical Hx of multiparity, heavy lifting
o Workup:
Cystocele: valsalva bladder moves down/positive Q-tip test (60 degreee
angle excursion or greater indicates cystocele)
Rectocele: diagnosed usually by history of difficulty with BM and the need
to apply pressure to the vagina to have a BM
o Treatment:
Mild -> pelvic floor exercises
Pessary device
Sacrospinous ligament fixation
Sacroplexy fixing the vaginal cuff with using mesh to the sacral bone
o Clinical Pearls:
Uterine prolapse:
Mild above the hymen
Moderate at the hymen
Complete beyond the hymen
Procedentia: entire uterus is prolapsed outside of the uterus
Case 58: Twin Gestation with Vasa Previa
o Clinical Pearls:
Case 14
Monozygotic twins are associated with a higher rate of fetal anomalies and
maternal complications
Maternal effects of pregnancy are enhanced in twin gestation: increase N/V,
anemia, BP, etc.
Twin transfusion syndrome should be considered with growth discordance
and discrepancies in amniotic fluid -> Tx: laser ablation of arteriovenous
malformations
Twin gestations without a dividing membrane is associated with a high
stillbirth rate due to cord entanglement
Velamentous cord insertion: umbilical vessels separate before reaching the
placenta -> susceptible to tearing after membrane rupture
Chorionicity: number of placentas
Amnionicity: number of amniotic sacs
Page 462 Table 58-1
Timing of Division Resulting chorionicity and amnionicity
First 72 hours Dichorion/diamnion
Day 4-8 Monochorion/diamnion
Day 8 Monochorion/monoamnion
After day 8 Conjoined twins
ObGyn Case Files 27

Case 59: Prenatal Care
o Page 467-480 Tables 59-1 to 59-3
Case 60: Lichen Sclerosis and Vulvar Cancer
o Differential diagnosis:
Lichen planus
Psoriasis: will have the presence of other silver scaley lesions
VIN: diagnosed on biopsy
Vitiligo
Candida infection: presents with uncontrolled diabetes and
immunosuppression
o Clinical Presentation:
Pruritus of the anogenital region in a figure eight pattern
Post-menopausal women
Itching worsens at night
Vulva is thinned with a cigarette paper appearance
o Workup:
Biopsy to rule VIN or vulvar cancer
o Treatment:
Steroid ointment -> clobetasol
o Clinical Pearls:
Lichen sclerosis histology: thinned epidermis, hyperkeratosis, and loss of
the rete pegs
Bartholin gland cyst: polymicrobial infection; treated with surgical drainage
either by a Word catheter or marsupialization
Lichen sclerosis patients have an increased risk of squamos cell carcinoma