You can get herpes even if condom are used.

If you get herpes and demonstrate high

risk behavior you should be screened for all STIs
Trichomonas discharge can be described as yellow,frothy and strawberry cervix
Culture is the gold standard for screening for herpes. Cultures should be done
earlier rather than laer. Unroof the lesion and scrape the base.
HPV screening should start at 21 regardless of coitarche. A young female says she
is having sex, give her STI screening.

Maternal Physiology
Hbg decreases due to dilutional anemia. For diluational anemia, MCV is normal (80-
100)
A hgb level of 10 is normal. If a pregnan woman presents with dyspnea with exertion
she likely has Physiologic Dyspnea of Pregnancy.
Pregnant women have a respiratory alkalosis via an increase TV. So pH is alkalotic
(> 7.4)< PO2 high, and PCO2 is decreased.
In a pregnant women IC, TV, and Minute ventilation are increased. FRC, ERV, and RV
are decreased.
Use of tocolytics (magnesium and ) increases the risk of pulmonary edema in
pregnant women. They are already at increased risk for pulmonary edema because
plasma osmolality is reduced to dilution. Chorioaminionitis can also increase the
risk by causing sepsis.
Up to 95% of pregnant women will develop a SYSTOLIC murmur due to increased CO.
Diastolic murmurs are abnormal and should be worked up.
A pregnant woman who develops right colicky pain but has signs negative of a UTI:
no dysuria or hematuria may just be experiencing symptoms of compression of the
Right ureter by the uterus and the right ovarian vein complex.
In pregnancy, Thyroid Binding Globulin and other protein carriers are increased.
Because this carrier isincreased then then the Free thyroxine levels are reduced.
In order to regain balance, TSH is increased which then increases the TOTAL amount
of thyroxine and then restores the Free T4 levels. Hence in pregnancy, TOTAL
thyroxine is higher, Free T4 is normal, and TSH is slightly elevated.
A woman presents with signs of a molar pregnancy. B-HCG level has already been
measured at 1 million. What is the next best step: CXR to look for mets to the
lung. You should do a weekly repeat B-Quant to follow progression of the disease
after starting her on OCPs.
BMI < 18.5 WG = 28 - 40, BMI 18.5 - 24.9 WG = 25 - 35 pounds BMI 25-29.9 WG = 15-
25 BMI > 30 = 11-20 pounds

Preconception Counseling
A pregnant woman has a sibling who has full blown sickle cell disease. If the
carrier rate in the population is 1/10 what is the risk that her child will have
sickle. Since the mom does not have sickle cell disease you rule out rr from her
punnett square. Thus is a 2/3 chance that she is carrier. 1/10 that her husband is
a carrier and 1/4 that the child develops sickle cell.
To screen for genetic diseases in an African American couple order 1) Hemoblglobin
electrophoresis which can reveal sickle cell and Hbg C disease and 2) CBC which
can show alpha and beta thal from the RBC indices
In Ashkenazi jews, there is an increased incidence of Tay-Sachs disease, Cystic
fibrosis, Niemann Pick diease. Beta-Thal is seen mediterranean pops.
An asheknazi jewish woman and an Irish man decide to have a child. Their child is
at greatest risk of Cystic Fibrosis because they are both white. For the ashekanzi
diseases both the man and woman have to be ashkenazi jews.
Valproic acid for epilepsy treatment is associated with an increased risk for
neural tube defects.
For mothers with uncontrolled diabetes that get pregnant, the baby is at risk for
developing cardiac and central nervous system (neural tube) defects. May also have
genitourinary and limb defects.
CVS is performed at 10-12 weeks. It is used to determine chromosomal abnormalities
and can also test for mutations in the baby such as Cystic Fibrosis. Omphaloceles
and neural tube defects are diagnosed with prenatal ultrasound.
Cell-free DNA is the best test to screen for Down Syndrome. Cell-free DNA has a
positive detection rate of 99% for Trisomy 21 and a 0.2% false positive rate.
The risk of fetal loss with CVS is 1% regardless of a history of the mom having
miscarriages.
Fragile X is the most common form of inherited mental retardation. Down syndrome
is also a common cause of mental retardation but it is NOT inherited per se.

Antepartum Care
When a mother's LMP gestational age does not match up with a ultrasound age, you
obtain a DATING obstetrical ultrasound and use that to determine the GA of the
baby. The 1st trimester ultrasound is the most accurate measure of GA.
Cell-free DNA is the most effective test to screen for Down Syndrome and can be
performed as early 9 weeks. Nuchal translucency, PAPP-A, and Beta HCG is the 1st
trimester screen for down syndrome.

Peripartum Cardiology; prognosis based on improvement of the EF. Patient has to

meet the following criteria: develop cardiac failure in last month of pregnancy, no
other obvious causes, no history of prior heart disease, EF < 45%
The best thing to do after a pregnant woman is newly diagnosed with Gestational
diabetes is to teach how to monitor glucose levels at home and blood sugar
management with diet modification. Don't give an oral agent or insulin until she
has tried changing her diet. (Also if she is + for GLT and + for the GTT, you don't
need any more tests).
The risk factors for gestational diabetes are 1) previous large baby delivery (> 9
lb) 2) abnormal glucose tolerance 3) Obesity 4) Race: Native americans and
Hispanics
Pregnant women with pre-existing diabetes are at risk for cardiac, nervous system
deformities and intauterine growth restriction. Pregnant women that develop
Gestational diabetes are at risk for polyhydraminos, fetal macrosomia, shoulder
distocia, and preeclampsia.
All women who have had a previous pregnancy with a Neural Tube Defect should ingest
4 mg of folic acid as a prenatal vitamin. The dosage for non-high risk women is 0.6
mg/day.
Taking valproic acid during pregnancy increases the risk of neural tube defects.
Caudal regression syndrome is a rare syndrome seen in the babies of mothers with
uncontrolled diabetes. It is when there is abnormal fetal development of the lower
spine (absence of tail bone, pelvic bones etc).
In terms of diet a pregnant mom needs FOLIC acid, iron and at about 70 grams of
protein a day.
Underestimation of gestational age is the most common cause of an elevated MSAFP in
a 1st trimester screen. Elevated AFP can also be caused by fetal demise, multiple
gestation, and ventral wall defects.
Amniocentesis is an invasive diagnostic testing used to detect Down syndrome and
other chromosomal abnormalities that is done in the 2nd trimester > 16 weeks.
1st trimester screen consists of 1) Nuchal Translucency where the fluid collection
at the back of the fetal neck is measured; a thickned NT is assoicated with fetal
chromosomal and structural abnormalities 2) PAPPA and 3) Beta HCG.
For anticoagluation during pregnancy: Warfarin is teratogenic. Heparin is ok but
LMWH is best for mothers. Ibruprofen (NSAIDS) are safe to take until 32 weeks where
there is a risk of premature closure of the ductus arteriosus.

Intrapartum Care
Braxton hicks contractions are irregular, painless contractions that are short in
duration. True labor is defined as regular, strong uterine contractions that
cause progressive cervical dilation and effacement.
Glycosuria in pregnancy can be normal.
In general, GBS swab is taken at 36 weeks in all pregnant women and if positive
treated with intrapartum penicillin. However, if a woman currently has GBS
bacteruria or has delivered a baby in the past who was infected with GBS then she
gets intrapartum penicllin for prophylaxis. There is no need to swab.
When a pregnant women who is term presents to the hospital in early labor the 1st
step is take a history focusing on antenatal complications and dating and targeted
physical exam looking at the mom's vitals, fetal heart rate, abd and pelvic exam.
The 2nd step is a speculum exam with Nitrazine test to confirm rupture of
membranes.
A mom who is early labor is unable to sit still so that the Fetal heart rate can be
meausred externally. Your next best step is to apply a fetal scalp electrode. Do
not give a mom epidural before confirming that the fetus is ok and ready for
delivery. IUPC (intrauterine pressure catheter only gives information about the
strength and frequency of the patient's contractions.
If a mother is having a hard time delivering her baby and the baby's heart rate is
low but the baby is found to be a in a good position (left occiput) has a +2 fetal
station, the best step si to produce to operative vaginal delivery with forcpes or
vacuum assisted delivery. Key point is baby's heart rate is low, baby is in
trouble, deliver as fast as possible. In this case contiuning with vaginal is the
fastest way.
After an IUPC is placed, the mother squirts 300 cc of blood. The blood could
indicate placental separation or uterine perforation. The next best step is 1)
remove the catether 2) Monitor the fetus and look for any signs of fetal
compromise. If the baby is ok, then you can try again to place the IUPC.
The most common cause of variable deceleration during labor is umbilical cord
compression. Oligohydraminos increases the risk of having umbilical cord
compression. Placental insuffiiciency is associated with late decelerations. Head
compressions cause early decelerations. Umbilical cord prolapse causes sustained
fetal bradycardia.
In labor, 5 cm of the umbilical cord is palpated in the vagina = Umbilical Cord
Prolapse. You should elevate the fetal head with a hand in the vagina so it
doesn't compress the cord and PERFORM a C-SECTION. Do not allow the patient to
continue labor.
A patient says I don't want to have anal incontinence from an episiotomy. You tell
her the best way to avoid trauma to the perineum, urinary or anal incontinence is
NOT to perform an episiotomy.

Immediate Care of the Newborn

With a baby with a flattened nasal bridge, small size and rotated cupshaped ears
you should be thinking of Down syndrome and should for other signs which include
sandal gap toes, hypotonia, protruding tongue, short broad hands, simian creases
(one big crease), epicanthic folds, and oblique palpebral fissures.
Mom has rupture of membranes and it is found to have meconium. You should deliver
the baby and if the baby is depressed then intubate the trachea and suction
meconium or other aspirated material from beneath the glottis. Meconium stained
amniotic fluid is seen in 12-22% of women in labor and Meconium aspiration syndrome
occurs in 10% of infants.
The baby of a mother with Type 1 diabetes (diagnosed before pregnancy) is SMALL and
hypoglycemic. Type 1 diabetes = Small babies Gestational Diabetes = Large
Babies. Both are hypoglycemic because the babies have elevated insulin levels in
utero due to mom's high blood glucose levels. This persists after their delivery
making them hypoglycemic.
Babies with chorioamnionitis present with fetal tachycardia in response to the
mom's fever. Fetal tach with minimal variability indicates that the baby may be
septic. Septic babies are pale, lethargic, and are febrile.
In a monochorionic pregnancy, Twin-twin transfusion syndrome can occur where due to
an imbalance in blood supply twin A is overperfused and becomes polycethmic and
twin B is underperfused and becomes anemic and develops IUGR and oligohydraminos.
Twin A is at risk of developing volume overload and polyhyraminos which can lead to
heart failrue and hydrops.
Babies born to mothers with gestational diabetes can develop hypoglycemia,
polycythemia, hyperbilirubinemia, hypocalcemia, and respiratory distress. They
present as macrosomia with a ruddy color and jitteriness.
A mother on marajuana delivers a baby with no respiratory effort. You should give
positve pressure ventilation and prepare to intubate the baby. You SHOULD not give
Naloxone in a mother who is supsected of drug use as it could cause life-
threatening withdrawal in the baby.
An HIV mother delivers an infant. The first thing you should is START AZR
immediately afer delivery. You can test the baby for HIV once the baby is 24 hours
old. This should make sense if the baby has HIV it has HIV but if you give the baby
meds right after delviery there is a chance that you could prevent the baby from
having it. So treat first; screen later!
HIV + mothers should not breastfeed.
The sniffling position (tilt the babys head back and lift the chin) is the correct
positon for applying positive pressure ventilation to an infant. Also make sure
the mask is secured over the infant's face, stop squeezing bag as soon as you
seechest rise, and the flow rate should be 10 L/minute.
APGAR Score is Heart Rate Respiratory Rate Reflex Activity
Color. Each category ranges from 0 to 2.

Post-Partum Care
Post-partum hemorrhage is defined as a blood loss of > 500 ml after vaginal
delivery or > 1000 L after C-section.
Uterine atony (failure of the uterus to contract) is the most common cause of
postpartum hemorrhage. Occurs 1/20 deliveries.
Sheehan syndrome is infarct of the pituitary gland because of post-partum
hemorrhage. Recall that pituitary grows during pregnancy (prolactin increases) and
post-partum hemorrhage can cause an infarct of this "larger pituitary" which is
used to getting a bigger blood supply. The presenation is slow mental function,
weight gain, fatigue, hair loss (hypothyroidism due to loss of TSH), hypotension
(no Cortisol), and amenorrhea (no FSH or LH).
Endometritis occurs more commonly in C-section (5-10%) than vaginal deliveries
(3%). Risk factors for endometritis in a vaginal birth are prolonged labor,
prolonged ROM, internal fetal monitoring, removal of the placenta manually, and Low
socioeconomic status.
The most common cause of postpartum fever is ENDOMETRITIS. Things to consider on
ddx are UTI, wound, and pulmonary infections.
After an uncomplicated C-section, a woman develops fever on the 3rd day and has
uterine fundal tenderness. She probably has endometritis.
Endometritis is usually caused by a polymicrobial infection: both aerobic and
anaerobic bacteria but the most common organisms are Staph Aureus and
Streptococcus.
Pueriperium - the period of about six weeks after childbirth during which the
mother's reproductive organs return to their original nonpregnant condition.
Post-partum Blues = lasts < 2 weeks no thoughts of suicide or harming baby
Post-partum depression = > 2 weeks and Patient may have thoughts of suicide or
harming the baby
The biggest difference between Post-partum depression and Post-partum blues in that
in post-partum depression the patient may be unable to love her family or have
"ambivalence" towards her baby.
The most important risk factor in developing post-partum depression is a HISTORY of
depression. Other risk factors include marital conflict, lack of social support
from family and friends, having contemplated termination of pregnancy, and
stressful life events.
If a mother tells you that she does not want to breast feed, the best way to
suppress Lactation is breast binding, ice packs, and analgesics. The patietn
should avoid breast stimulation.
Breast feeding decreases the risk of developing ovarian cancer and may decrease
Breast cancer too.
Breast feeding is recommended for all infants. Infants should be breastfed
exclusively for the first 6 months of life.
Breast feeding calso causes increased uterine contraction due to oxytocin release
and less blood loss. Breastfeeding is also a major source of IgA to the baby which
reduces GI infections.

Lactation
The best position for a mother to breast feed is belly-to-belly which puts the
infant in a good position to latch on and fit the areola in its mouth.
Prolactin is responsible for milk production. Oxytocin is responsible for milk
ejection (oxy-tocin tocin milk out of the nipple).
Mother breastfeeding develops fever and red, tender, wedge shaped area on her
breast has mastitis and should be treated with dicloxacillin. Strep bacteria from
baby's mouth enters the cracks in the nipple.
Mothers with mastitis can still breastfeed unless they are found to be MRSA
positive. If MRSA switch to the other breast.
Hospital policies that promotes breastfeeding are 1) getting the baby on the breast
within a half hour of delivery and 2) rooming-in of the baby to ensure frequent
breastfeeding on demand (unlimited access).
During gestation, Progesterone inhibits the milk producing action of Prolactin.
Thus it may take up to 2 days for progesterone and estrogen to be cleared and milk
production begins.
A breastfeeding woman who presents with red, cracked painful nipples that are more
painful with feeding has a Candida infection. Treat with topical Clotrimazole or
miconazole cream. Abx are also usually given as Staph Aureus loves nipple
fissures. You also have to check the baby to see it has oral candidiasis and treat
with oral nystatin or oral fluconazole.
A woman who just delivered wants long term contraception, wants to lose weight and
wants to breastfeed for 6 months. The best contraception is IUD. Can't use Depo
provera or combined OCPs as the progesterone/estrogen would inhibit prolactin.
Signs that a baby is getting sufficiency milk is 3-4 stools in 24 hours, six wet
diapers in 24 hours, weight gain, and sounds of swallowing.
Breasts normally become engorged when milk first comes in. Treat this with frequent
nursing, warm showers or warm compresses to enhance milk flow, massaging and hand
expressing milk to soften breast, wearing a good support bra (not wire coil), and
analgesic 20 minutes before breast feeding.

Ectopic Pregnancy
Patient presents with signs and symptoms of ectopic: amenorrhea, vaginal bleeding,
and pelvic/abd pain but a B-HCG < 1500. Best step is to re-check B-HCG in 48 hours
to see if it has doubled or at least increased by 2/3. Then you can do ultrasound
to check for an intrauterine pregnancy.
The greatest risk factor for an ectopic pregnancy is a prior ectopic pregnancy. 1
ectopic increases risk to 10 % (10 fold increased risk) %. 2 or more ectopic
pregnancies increase risk to 25%. Adv maternal age is also a risk factor. So is
STIs, endometriosis, and congenital malformations.
A patient with suspected ectopic pregnancy presents with acute abdomen (rebound,
guarding, or severe abd tenderness) or with unstable BP < 90 and increased HR then
assumed Ruptured ectopic and take to OR for Exploratory Laporotomy/Laparoscopy.
Progesterone level in a normal pregnancy is > 25 ng/ml.
30% of all normal pregnanices experience first trimester spotting/bleeding.
A woman is found to have a molar pregnancy. The first best step is Expectant
management. If that fails then consider giving Misoprostol, vacuum aspiration, or
D&C.
Mifepristone is a progesterone antagnoist and can be used as emergency contractipn
to prevent ovulation and prepartion of the endometrium. It is also used for
pregnancy termination.
A patient presents with a B-HCG above the discrminatory zone and no IUP has an
ectopic until proven otherwise.
The conditions to use MTX to treat an ectopic pregnancy that has not yet ruptured
are 1) B-HCG < 5000, 2) Ectopic mass < 4 cm or < 3.5 cm if it has a fetal heart
rate 3) Normal WBC, LIVer etc 4) Patient can reliably follow-up in case first dose
doesn't work and is Hemodynamically STABLE

Spontaenous Abortion
After undergoing a suction dilatation and currettage a woman develops rebound
tenderness and guarding and her uterus is soft and tender. She has a Uterus
Peforation. The other risks from a D and C are bowel and bladder injury, and
cervical laceration.
Hematometra- collection of blood in the uterus, can develop after an abortion and
presents with cyclic midline abdominal cramping.
The main cause of 1st trimester abortions are genetic abnormalities in the fetus
aka "genetic abnormalties involing the conceptus"
Autosomal trisomy is the most common abnormal karytoype for spontaneous abortions
(40-50%).
Systemic diseases such as diabetes, chronic renal disease, and lupus are associated
with early pregnancy loss.
1 prior history of pregnancy termnation does not increase your risk of a future
terminaton.
Environmental factors considered: smoking, alcohol, and radiation exposure can
cause spontaneous abortion.
A woman presents with heavy vaginal bleeding in 1st trimester. Hbg is 7 and she is
actively bleeding. Best next step is D and C to remove the products of conception
which is what is causin the bleeding.
If a patient is hemodynamically stable and is experiencing an abortion then
expectant management (let nature take it's course) can be used.
After every abortion, you should figure out the woman's blood type and give Rho-GAM
if indicated.
A woman who had abortions in the past because of an incompetent cervix should be
treated with a cerclage at 14 weeks to prevent a future abortion.
Positive fetal fibronetcin is used in later pregnancy as a negative predictor of
preterm delivery.
A patient aith APA should take aspirin or heparin.
Progesterone can be used to prevent recurrent abortion and preterm labor.
32 G3P0 where all 3 prior pregnancies ended in 1st trimester abortions. This
qualifies as a HABITUAL aborter and you should test for 1) Lupus, 2) Diabetes
Mellitus and 3) Thyroid disease. Look for abnomalities using hysteroscopy or
hysterography.
1st trimester Therapeutic abortions (d and C) do not increase the risk of 1st
trimester spontaneous abortions in the future.

Medical and Surgical Complications in Pregnancy

Type 1 diabetes dependent on insulin increases the risk of fetal growtth restrction
(small babies) and fetal cardial and neural tube defects.
Amytriptiline, levothyroxine, labetalol and acyclovir are all safe medications used
in pregnancy.
Lisinopril is teratgenic and is associated with oligohydraminos, fetal growth
retardation, and neonatal renal failure.
To decrease the transmission of HIV from mother to mom you should 1) treat mom with
HAART antepartum (before conception) and during pregnacy and at he delivery give IV
Zidouvidine in labor and Zidovudine treatment of the Neonate.
The most common cause of sepsis in pregnancy is acute pyelonephriis. So if a woman
presents with signs of sepsis think pyelonephritis.
Asthma worsens in pregnancy. If the pregnant women is having to use her SABA more
next step is to add an inhaled corticosteroid.
Thyroid storm in a pregnant woman CANNOT be treated with Radioactive iodine as I
would cause congenital hypothyrodism in the fetus. But u can give the usual
treatment of Propylthiouracil (not methamazole), Propanolol, Potassium iodide, and
steroids.
A patient is dx with syphillis. The best treatment is desensitize and give
penicllin G (IV).
Syphillis is screened with RPR (rapid plasma reagin test) and diagnosed with the
tropnema specific test FTA - ABS.
In an obese woman with a famil history of T2DM, you should start screening for
Gestational Diabetes ASAP. People at regular risk are screened at 28 weeks. Think
HSG at 28 weeks.
A woman at 26 weeks develops BV. Treat her with Metro as normal. Not treating
increases the risk of preterm delivery.
Women with pulmonary HTN have a 25-50% mortality risk when they become pregnant.
They are at risk because pregnancy can cause deminished venous return and decrased
right ventricular filling which is really important with someone with pulmonary
HTN.
Women with Marfans syndrome with Aortic involvement have a high mortality risk when
they become pregnant.

Medical and Surgical Complications in Pregnancy part 2

Murur with a systolic ejection click is Mitral valve prolapse. Most are
asymptomatic and found incidentally. If this is the case no treatment. If the
patient is symptomatic: has anxiety, palpitations, atypical chest pain, and syncope
then TREAT with Beta blockers.
pregnant woman with pneumonia: fever, chest pain, SOB, leukocytosis get a CXR
Alpha thal can present as a mild microcytic hypochromic anemia with a normal
hemogloblin electrophoresis.
Obesity increases maternal morbidity by increasing risk of chronic HTN, gestational
diabetes, pre-eclampsia, and fetal macrosomia.
The two most common causes of anemia during pregnancy and puerperium period are
Iron deficiency anemia and blood loss. Iron def is supported by hypochromia,
microcytosis, and no stainable iron on bone marrow aspirate.
Lupus in pregnancy is still treated with steroids. NSAIDS can be used to treat
arthralgia and serositis. Hydroxychloroquine can treat skin manifestations and if
d/c can cause lupus flares.
When a pregnant women presents with Breast cancer, you treat her like any other
woman with BREAST cancer. You treat the breast cancer with surgical resection, LN
removal if signs of metastasis, and give Chemotherapy BUT YOU DO NOT give RADIATION
as this can lead to mutations in the fetus.
Paroxtine is the only SSRI that is contraindicated in pregnancy as it cana fetal
cardiac malformations and pulm HTN.
Fluoxetine, Sertraline, and Citalopram are OK to use in pregnancy.
When a woman presents with cholestasis of pregnancy: itchy palms and feet and
signs of jaundice. First line treatment is topical emollients or antihistamines and
then treat her with ursodeoxycholic acid.
When a pregnant women comes in with GI complaints, fever, Right-sided abdominal
pain the main thing you should try to rule out is APPENDICITIS! Perform a
compression ultrasound to investigate.

Preeclampsia
The classic signs of magnesium toxicity are 1) muscle weakness and loss of Deep
tendon reflexes 2) Nausea 3) Respiratory Depression 4) Cardiac depression at high
doses.
If a woman with preeclampsia being treated with magnesium suddenly experiences a
drop in RR then STOP magnesium.
To differentiate Preeclampsia from Gestational HTN you have to measure urine
protein with 24 hour urine collection. Urine protein > 300 mg + BP >140/90 =
Pre=eclampsia Urine protein > 5g or BP > 160/105 = Severe preeclampsia
Preclampsia + Seizures = Eclampsia
Edema is a sign of Preeclampsia.
The only definitive treatment for preeclampsia is DELIVERY. You should manage the
patients with fluids, Magnesium sulfate during labor and 24 hours postpartum to
lower seizure risk, and Hydralazine to reduce BP.
A preeclamptic patient is actively having a grand mal seizure. You treat with
MAGNESIUM sulfate as 1st line. If that doesn't work then you can try Valium
hydantoin, tigabine, and barbituates
Risk factors that increase risk of Preeclampsia 1) having preeclampsia before 2)
chronic HTN 3) multiple gestations 4) Race/ethinicity 5) Extremes of age, and 6)
Molar pregnancy. Hx of spontaneous abortion is not a risk factor.
Therapeutic level of Mg is 4-7. At 11 the woman will have resp depression. At 15,
cardiac arrest.
If a woman with Severe preeclampsia is being treated with expectant management
because she is not term and she develops thrombocytopenia (<100,000) you have to
treat her ie you have to do something. DELIVER. Other reasons to deliver in this
case are 1) BP is not conotroleld with 2 antihypertensives 2) Non-reassuring fetal
surveillance 3) LFTs elevated more than twice normal 3) Eclampsia (seizure) 4) CNS
symptoms and 5 )Oliguria.
HELLP is a severee form of preclampsia. Hemolyisis - increased bilirubin;
elevated liver enzymes- AST/ALT low Platelets. You dont need to have hemolysis
to have HELP.
Acute fatty liver manifests LATE in pregnancy. It presents with malaise, anorexia,
n/v, epigastric pain, progressive jandice. Severe liver dysfunction with
hypofibrinogenemia, hypoalbuminemia, and hypocholesterolemia. No HTN or
protienuria.
Third trimester bleeding, consider Placental abruption. Evidence of Fetal anemia
(tachycardia and Sinusoidal heart rate), frequent contractions on toco are signs of
abruption.
Pregnant woman at 36 weeks present with a BP of 200/105. Reduce her blood pressure
until her diastolic range becomes normal ie in 90s - 100s.

Rh Immunization
After any procedure where an Rh- mom comes into contact with Rh+ blood there is a
risk of alloimmunization and RhoGAM should be given. This includes: CVS,
amnioncentesis, threatened abortion, ectopic, D&E, placental abruption,
preeclampsia, C-section
If a woman refuses post-partum rhogam, the risk of allominnuzation is 2% antepartum
and 7% after full term delivery and 7% with subsequent pregnancies. Ie in total she
has a 20% chance of developing alloimmunization.
doppler ultrasound of the middle cerebral artery can used to check for fetal
anemia. It measures the peak systolic velocity of blood flow.
Fetal hydrops is defined as collection of fluid in 2 or more body cavities aka
ascites, pericardial fluid, pleural fluid, or scalp edema. It is due to decreased
hepatic production.
300 micrograms of RhoAm neutralizes 30 cc of fetal blood.
After amniocentesis in a Rh - mom give RhoGAM
Rhogam is given to every Rh- mom at 28 weeks and within 72 hours after delivery
even if she has negative D antibodies (the purpose is to prevent mom from ever
developing antibodies). The only exception is if the Father is also known to be Rh
(-)
Lewis antibodies are IgM and do not cross the placenta and thus cannot cause
alloimmunization disease.
Bilirubin in amniotic fluid is an indicator for severe hemolysis and thus severe
alloimmunization.
Amniotic fluid ferritin is assoicated with spontaneous preterm delivery.
Mom's baby has severe alloimmunization at 30 weeks. The next best step is
intrauterine intravascular transfusion to give the baby blood.

Multiple Gestations
Multiple gestations can present as 1) Fundal height that exceeds gestational age
and 2) Elevated AFP (For twins it should be twice the AFP seen in a single
pregnancy)
Ultrasound findings of dizgyogtic twins include 1) a dividing membrane > 2 mm in
thickness 2) Lambda sign (twin peak), 3) different fetal genders 4) Two separate
placentas (anterior and posterior).
Di chorio Di amnio < 4 days Mono Chorio Di amnio 4-8 days, Mono Chorio Mono
Amnio - 8- 12 days Conjointed twins - 13 days
The death rate for twins is five times greater than single pregnancies. The risk
of cerebral palsy is twins is 5-6 times greater than single pregnancies.
58% of twins are delivered prematurely with the average of age of delivery 35
weeks.
Incidence of congenital abnormalities is greater in twins than in single
pregnancies.
Adequate weight gain in 1st 20-24 weeks of pregnancy is important for women
carrying multiple pregnancies to help reduce preterm/low birth weight
Twin-twin tranfusion syndrome occurs in monochorionic diamniotic twins. < 4 = Di Di
4 - 8 Monocho Diamniotic 8-12 mon mono
Infants that survive twin-twin tranfusion have increased rates of neurological
problems and Cerebral palsy. The fat twin can develop HF, Cadiomegaly,
T regurg, V hypertrophy so heart problems. The donor twin is anemic, hypovolemic,
and growth restricted. Either twin can develop hydrops fetalis. Skinny becomes
hydropic from high-output heart failure.
The most concerning complications for multiple gestations is pre-term birth.
With twins, if the first infant A is in Breech then peform C-section. If twin A is
vertex and twin B is breech then you can try vaginal delviery for both.
Twins or multiple gestations will present with size-date discrepancies. Your first
step should be U/S to explore this.

Fetal Death
Autosomal trisomy is the most common karyotype seen in spontaneous abortions. (the
most common in SAB is Trisomy 16)
The risk of fetus developing microcephaly and intellectual disability is greatest
8- 15 weeks gestation.
50 rads at less than 8 weeks is ok..
A pregnant women with a history of DVTs, fetus with assymetric growth restriction
likely has Factor V Leiden. It is associated with stillbirth, preeclampsia,
abruption, and IUGR.
Factor 5 leiden is the most common inherited thrombophilic disorder affecting 5% of
whit women. Heterozygous 5-10 fold increased risk, Homozygous 80 fold increased
risk of thrombosis.
Baby with macrosomia, NTD - the mother most likely had diabetes. Uncontrolled
chronic diabetes causes fetal growht restriction and heart and NTD
Hx of cone biopsy increases risk of cervical incompetency.
A woman with vaginal bleeding in the context of an abortion should have her blood
type checked to see if she needs Rho-GAM
No fetal heart rate = definitive evidence that the fetus is no longer viable. No
need to measure B-HCG levels Progesterone levels c an be measured to see if a
pregnancy is failing.
Uncontrolled diabetes is associated with fetal death, macroscomia (if
gestational), and growth restriction (if chronic)
Stages of Grieving/dealing with pregnancy loss: Denial, Anger, Bargaining,
Depression, and Acceptance DAB DA
With a mom who has just had fetal demise, allow her to decide when to deliver.
Ensure that you offer autopsy and biopsy to help determine the cause of death.
Offer to have someone take pictures and collect mementos for the parents
Missed abortion on U/S = Crown Rump Length > 7 mm with no cardiac activity

Abnormal Labor
The major cause of higher C-section delivery is VBAC has decreased. And less OB are
willing to try vaginal breech delivery due to lack of training.
Women has arrest of active phase of Stage 1 labor (> 4 hours with inadequate > 6
hours with adequate)
What is the definition of "adequate contractions" q 3-4 or q 2-3
The first step to inducing labor is to give Cytotec before giving pitocin. You
cannot use a foley bulb or ROM on a closed cervix. The cervix has to be open first.

Fibrids are associated with Breech presentation. So are prematurity, multiple

gestation, hydro and an cephaly, and placenta previa.
With adequate contractions, you have to wait for 6 hours before calling "arrest of
active phase of labor"
Active phase of labor is defined as the cervix > 4 cm
Arrest of the latent phase of labor is > 20 hours for nulliparous women and > 14
hours for multiparous women. Treat with rest or augmentation of labor.
The biggest risk factor for shoulder dystocia is macrosomia from diabetes. Others
include maternal obesity, post-term pregnancy, prior hx of shoulder dystocia,
prolonged 2nd stage of Labor
6 hours in active phase of labor with adequate contractions ---> Too long --> So
try ROM (amniotomy) or augmentation with pitocin.
For Stage 2 of labor, Nul parious get 3 hours. Multiparous get 2 hours.
Anyone with a Category 3 tracing gets a C-section.
Frank breech > Footling > Complete Breech

Third Trimester Bleeding

Normal labor is 1cm/hour in a nullparous. Multi parous can be 1-2cm/hour. Faster
than this is abnormal.
During labor a little bit of blood is normal but a LARGE amount of bleeding should
raise concern for placental abruption.
Placenta previa presents as painless bleeding in 3rd trimester; treat with DELIVERY
via C-section
Repeat C/sections increase the risk of accreta. 4 prior c-sections = 50% risk. -
Scar tissues from prior pregnancies forces the placenta to dig deeper into the
myometrium.
Fresh Frozen Plasma contains V Fibrinogen 8. Cryoprecipitate contains VWF
Fibrinogen 8
Cocaine + abd pain + tender uterus or uterus hypertonia + vaginal bleeding + fetal
Tach/Distress = Abruption Treat with C-section and IV fluids/Blood products
RF for abruption smoking, cocaine, chronic HTN, trauma, Prolonged PROM, hx of
prior abruption.
Signs of abruption in context of contractions --> Still go str8 to C-section. No
need for tocolysis -
Risks to the mother from placental abruption are 1) Massive hemorrhage 2) DIC 3)
possible Hysterectomy.
Smoking increases the risk of abruption, previa, IUGR, preeclampsia, and infection.

Bloody show is when the cervix bleeds as it dilates during labor. It is usually
normal but requires r/o of ther abruption or previa or recently)
Vaginal bleeding in a woman with a closed cervical os who is not in labor could be
due to cervicits from infection (especially so try to r/o.
Cervical cancer can also be a source of vaginal bleeding in someone who is a smoker
and has had no care.

Preterm Labor
The most common cause of preterm contractions is Idiopathic. Dehydration and
uterine distortion from fibroids are also associated with preterm labor.
Cervical incompetence presents with painless cervical dilation in the 2nd
trimester.
When someone is in preterm labor and you are unsure of their GBS (as you will since
they are preterm) give a Tocolytic, Steroids, and Ampicillin to cover Group B strep

Terbutaline and ritodrine are ctind in diabetes. Nifedipine ctind in cases of fetal
hypoxia. Magnesium Sulfate is contraindicated in MYASTENIA GRAVIS.
Mother is in preterm labor, has a fever and high white count with a reassuring
heart tracing and vertex presentation. You should induce labor to deliver the baby
vaginally.
Mg sulfate works as a Tocolytic by competing with Calcium for entrance into cells.

SE of terbutaline are tachycardia, hypotension, and anxiety and chest pain.

Terbutaline SHOULD NOT be used for more than 48 hours. Consider Mag and Nifedipine
for longterm treatment.
SE of Mag 1) at 7-11 loss of deep tendon reflxes 2) 12-15 - Resp depression 3) >15
Cardiac depression
Steroids for preterm birth have the advantages of 1) dec NEC, 2) dec RDS, 3) dec
intracerebral hemorrhage
Fetal fibronectin test has a high Negative PV to rule out preterm labor. It can be
used in women with preterm labor from 24 to 25 weeks.

PROM
To rule out PROM, you should examine VAGINAL FLUID and not cervical mucus. You can
look for ferning or test with Nitrazine blue.
Tocolysis can be given in the setting of PROm to prolong the interval of delivery
to give the baby STEROIDS. Cannot use beyond 48 hours or after 36 weeks due to
increased risk of chorioamnionitis.
Genital tract infections especially BV are the most common cause of PROM. (Smoking
and prior PROM can increase the risk.
Variable deep deceles are caused by CORD compression which can be caused by
oligohydraminos from PROM.
Treat PROM with Ampicillin and Erythromycin. This prolongs time before delivery by
5-7 days.
Oligohydraminos is NOT an indication to deliver.
Fetal lung matury occurs by 34 weeks gestation and can be supported by positive
phostahidylglycerol in vaginal fluid.
Maternal signs of chorioamnionitis or other signs of an infection are an indication
to deliver.
PROM + tender uterus = Chorioamnionitis
Oligohydraminos leads to Potter's Sequence = Pulmonary Hypoplasia, Flattened
facies, low set ears --> usually due to renal anomalies or ROM before viability.
Amniotic glucose < 20 mg (low) or elevated IL-6 indicates an intra-amniotic
infection. Can perform amniocentesis to measure these values.
17 alpha hydroxyprogesterone is given to reduce the risk of premature labor and for
PROM.
No need to give steroids after 32 weeks.

Intrapartum Fetal Surveillance

IUPC is used to determine whether contractions are adequate.
Prostaglandins are contraindicated in patients with a history of c-section because
of the increased risk of uterine rupture.
Cervidil = PG E2 = Dinoprostol Cytotec = PGE1 = Misoprostol
A fetus with late decels is not tolerating labor as late decels = uteroplacental
insufficiency (non-reassuring heart tracing) so your next step is delivery.
Terbutaline is contraindicated in patients with Tachycardia as it could make it
worse.
Variable decels = 1) Acute fall in FHR with a rapid sharp slope and variable
recovery phase. Associated with cord compression.
Sine wave = 2-5 waves per cycle and an amplitude of 5-15 beats per minute.
Late decels are a symmetric fall in the FHR beginning at or after the peak of a
uterine contraction and returning to baseline after the contraction has ended.
Associ with uteroplacental insufficiency.
When you notice fetal hypoperfusion via LATE decels, your course of action is 1)
Position of mother (left lateral) 2) Give mom O2, 3) Treat Maternal
hypotension 4) Stop Oxytocin 5) Give IV fluids and give tolcolytics maybe
amnioinfusion. 6) C-section
A baby during delivery has minimal variabilit with no accels your steps are 1)
Fetal stimulation 2) Fetal pH or vibroacoustic stimulation or allis clamp test. You
are concerned about fetal Acidemia
Uterine hyperstimulation causes persistent BRADYCARDIA.

Post-Partum Hemorrhage
Uterine Atony is the most common cause of POSTPARTUM hemorrhage. RF include a
difficult labor, multiparity, general anesthesia, oxytocin, prolonged labor,
macrosomia, twins and chorioaminoitis aka a "ROUGH LABOR"
Methergine is contraindicated in women who have HTN or Preeclampsia.
Hemabate = Prostaglandin F2-alpha and is contraindicated in patients with asthma
A globular pale mass = Uterine Inversion RF are anything that causes an over-
distended uterus: grand multiparity, multiple gestation, polyhydraminos, macrsomia

PPH = > 500 cc for vaginal and 1000 cc for C-section

Retained placenta - HTN so methergine is out.
With PPH, you have to 1st r/o is the uterus 2nd r/o the placenta 3rd r/o tissue
lacerations.
Oxytocin should not be given as an IV push.
C-section increases the risk of accreta which can then cause post-partum
hemorrhage.
Boggy Uterus = Uterine Atony
B-lynch compression suture is used to manage uterine atony. If that fails then
ligate the internal iliac artery.

Postpartum Infection
Treat endometritis with Clinda and Gent.
Breast engorgement can cause a low-grade fever. Of course Breast engorgement can
lead to mastitis which can then lead to a full blown fever.
The postpartum fever dx includes endometritis, cystitis, mastitis, PNA wound
infections and lastly Septic Pelvic Thrombophlebitis.
Postpartum fever that is unresponsive to abx = septic thrombophlebitis. It is a
DOE.
R/o 1 endometritis, cystitis, mastitis, PNA (w CXR) wound infection and SPT
Endometritis is treated with Clinda and Gent
Epidurals can lead to spinal headache, localized back pain, and MENINGITIS.
Pregnant women complains of RUQ pain, n/v, and has a white count nad abnomal AFTs -
think Cholecystitis

Anxiety and Depression

Post-partum blues = < 2 weeks (blue weeks with no thoughts of harming self or
baby). Postpartum depression = > 2 weeks +/- thoughts of harming self or baby
Patient with "admitted" thoughts of suicide or self-harm with a plan should be
adimitted to inpatient psych
SSRI are helpful in patients with post-partum depression.
A hx of depression increases a woman's risk of developing post-partum depression.
Insomnia is one of the most common SE from Fluoxetine. Also sexual dysfunction
(decreased libido and delayed or absent orgasm).
SSRI are safe to take when a mom is breastfeeding.
3rd trimester use of SSRIs can cause extrapyramidal SE and withdrawal symptoms in
the baby: sleepiness, severe difficulty breathing, and difficulty in feeding.
Anyone who is depressed, you ask about thoughts of suicide.
Any woman who comes in with PMS the first step is to diary her PMS symtpoms.
"Ascertain the timing of her symptoms each month" Gotta rule out other psychiatric
diseases
A hx of depresson is the biggest RF for developing postpartum depression.

Post-term pregnancy
Late term and post-term pregnancies should be followed with antepartum fetal
surveillance with fetal kick counts, Amniotic fluid volume and non-stress testing,
Contraction stress testing or BPP if they have oligo or nonreassuring testing.
Post-term pregnancies are associated with placental sulfatase deficiency, fetal
adrenal hypoplasia, and ancephaly.
Late term and Post-term pregnancies are associated with macrosomia,
oligohydraminos, meconium aspiration, and uteroplacental insufficiency (because the
placenta is too old) and dysmaturity.
Late term = 41 weeks 0 days to 41 weeks 6 days Post-term = > 42 weeks
Amnioinfusion is given to prevent variable decels from cord compression.
Meconium stained amniotic fluid is more common in late and post-term as their
bowels are fully developed.
Woman comes in with a favorable cervix and she is at 41 weeks or more then induce
her.
Woman comes in with an unfavorable cervix (long and closed) and may or may not be
posterm (questionale GA) then follow with antepartum fetal testing (twice weekly
non-stress tess and amniotic fluid index)
Babies with fetal dysmaturity are described as withered, meconium stained, have
long finger nails, and have a small shriveled placenta. They are at greatest risk
for stillbirth.
Always give cytotec(misoprostol) before oxytocin. Gotta ripen the cervix because
contracting the uterus.
You cant' strip membranes in a patient with a closed cervix.
The greatest RF for having a post-term pregnancy is a hx of post-term pregnancy.

Fetal Growth Abnormalities

The main cause of fetal growth restriction is uteroplacental insufficiency or
decreased perfusion to the baby.
When a baby has fetal-growth restricion you should assess how the baby is doing.
Look for Oligohydraminos by measuring amniotic fluid volume. Look at the S/D ratio
of the umbilical artery to see if there is increased vascular resistance which may
be the cause of the FGR. An increased S/D ratio indicates increased resistance.
Once you diagnose FGR, the fetus needs to undergo twice weekly BPP and other
measures of fetal well being: NST: fetal heart rate measured over 20 mins to look
for accels, Biophyscial Profile which includes NST + Ultrasound until it is ok for
the baby to be delivered.
1st trimester crown-rump length is the most accurate measure of GA.
Polyhydramnios is NOT associated with FGR since it FGR you have poor blood flow
thus the kidneys won't produce that much fluid.
Babies with FGR restriction are at increased risk of developing cardiovascular
disease, chronic HTN, stroke, COPD, and T2DM as adults. No cardiomyopathy.
IUGR with oligo, abnormal umbilical artery studies, reversed diastolic flow at 36
weeks. This baby is not doing well and is close enough to term so deliver.
Macrosomia = at or > 90% for GA.
Macrosomic babies are at increased risk for birth trauma: shoulder dystocia and
brachial plexus injury. Hypoglycemia and Jaundice because usually the mom has
gestational diabetes.
U/s is a good way to estimate fetal weight but may be unreliable in macrosomic
fetuses.

Obstretic procedures
u/s crown to rump length in 1st trimester is the most accurate way to date GA
If fatty white tissue is seen during a D/C stop because that may be omentum from
bowel. Stop the D/C and follow-up with Laproscopy to see if the bowel was actually
involved. If it is proceed to Laparotomy.
You do a C-section for a fetal head measuring greater than 12 cm.
If a large uterine fibroid is located in the lower uterine segment and may obstruct
labor then you can do a C-section.
Vaccuum or suction extractors have a lower risk of lacerations to mom but can cause
cephalohematoma on the fetus which then increases the risk of jaundices and
transient neonatal lateral rectus paralysis. You can also get lacerations in the
baby at the head of the vacuum cup if torsion is applied.
Post-term pregnancies, PROM, oligohydraminos are indications for induction of labor
.
However the 6 cases are absolutes for C-section 1) Abrupton 2) Previa 3) fetal-
pelvic disproportion 4) Malpresentation 5) Umbilical Cord Prolapse
6) Non reassuring FHR,
THERE I sNO SUCH thing as POST-TUBAL LIGATION syndrome. NEVER PICK IT as an answer.

The greatest risk after tubal ligation is an ectopic pregnancy.

CVS can be done earlier around 10 weeks but has a greater risk of fetal loss 3 %.
CVS also more often requires repeat studies. Chorioamniocentesis has to be done
later at 15 weeks but has a lower risk of fetal loss (0.5% to 1%).
Hx of cervical insufficiency get a prophylactic cerclage at 14 weeks.

Contraceptions
"Emergency Contraception
3 days vs 5 days
Just progesterone so they cannot harm pregnancy

Progestin-only pills (mini-pills) are good for women who have a DVT in the past.
But careful using Progrestin pills only in women with a depression.

Women who have a DVT, 35 or older and smoke, lactating, or develop nausea should
not take combined OCPs.

Combined OCPS can decrease a woman's risk of endometrial and ovarian cancer by
stopping ovulation.

HTN can be a SE of OCPs.

"

The greatest risk factor for regreat after sterilization is age of sterilization.
Younger you are the more likely you are to regret. Other RF include not being
married, disagreement with husband.
For women seeking sterilizaiton, vasectomy is the easier and more feasible option.
Poorly controlled HTN is a contraindication to combined OCPs.
Hx of Wilson and menorrhagia are contraindications to Copper IUD
Transdermal patch should not be used in obese women since it has a higher failure
rate.

Abortions
Septic abortion = Vaginal bleeding, Cervix open + fever. Treat with uterine
evacuation and broad-spectrum abx. You would not use medical abortion as this is an
emergency and the fetal contents need to come out ASAP.
Threatened abortion = Vaginal bleeding , Cervix closed (no fever)
APA associated with early recurrent pregnancy loss. Measure anticardiolipin and
beta-2 glycoprotein antiboid status, PTT, and Russel viper venom time
Factor 5 is associated with thrombotic events that can affect the growing fetus but
does NOT cause early pregnancy loss.
Treat APA with aspirin and heparin.
Medical abortion (Mifepristone and Misoprolstol) is associated with higher blood
loss than surgical abortion.
Vacuum aspiration is typically done for fetus less than 8 weeks as it has a higher
chance of success 99%.
Mifepristone a progesterone antagonist is a pregnancy terminator. Misoprostol
softens/ripends the cervix.
When someone who used medical abortion presents with heavy bleeding, next step is
go to the OR for D/C
Someone presents with a tender uterus and fever a few days after a D/C for elective
abortion. You should 1) Give IV abx 2) use ultrasound to look for products of
conception

Vulvar and Vaginal Disease

3 months malodorous discharge, no itching BCT CT are itchy. B is not itchy but
smelly. T is trash so melly
BV is the most common cause of vaginitis .treat with Metronadizole PO or Gel.
Lichen sclerosis affects caucasian premenarchal girls and postmenopausal women.
Autoimmune but cause unknown. Dry white, itchy perineal region. Classic PE
signsare introital stensosis and resorption of the clitorsis (phimosis) and loss
of labia minora. Ie loss of normal architeture. Treatment is high potency steroids.
Increased risk of SCC
Lichen planus - lacy reticulated pattern of the labia, perineum. Progressive
adhesions and loss of architecture. Presents with vulvar irritation, burning,
itching, and contact bleeding. PATIENTS ALSO HAVE ORAL lesions. Alopecia and
extragenital rashes.
Treat vestibulodynia with Tricyclic Antidepressants to block pain loop, pelvic
floor execises, biofeedback and topical anesthetics. Surgery is a last resort.
Lichen simplex chronicus (lichenification) is a common vulvar disease that results
fro chronic scratching and rubbing hat damagesthe skin. Symptoms are vulvar
intching that is worse at night, PE shows lichenified, enalrged and rugose labia.
Dx with vulvar biopsy. Treat with short doses of teroids and antihistamines.
Whenever any kind of lesion is seen on the vulva your next step is BIOPSY.

Sexually Transmitted Infection

Primary/initial HSV infection is characterized by a viral-like symtom preceding the
appearance of vesicular genital lesions. Tx with sitz baths and perineal care or
xylocain jellies and Acyclovir. You can also get dysuria leading to urinary
distention. Tx this with catheter drainage.
Early syphillis includes stage 1 stage 2, and early latent (infected within the
past year).
Hep B can be spread sexually. If someone has exposure and is not immunized, give
HepBIG and Vaccine series. (7 days within blood contact and 14 days within sexual
contact). If they are immunized do nothing.
No evidence that if someone is adolescent you should treat them with inpatient. But
having a HIGH fever is enough to treat as an inpatient.
Acute salpingitis / tubo-ovarian abscess = PID
Can use Cefoxitin + doxycline or Clinda + gent to treat PID. Outpatient
Ceftriaxone + Doxy +/- Metro
Sequelae of PID = infertility, ectopic pregnancies, and chronic pelvic pain.

Pelvic Relaxation and Urinary Incontinence

Overflow incontinence = failure to empty bladder adequately so high Post Void
Residual volume (> 300 cc). A normal PVR is 50-60 cc.
The RF for the development of POP are increased parity, increasing age, connective
tissue disorders, chronic constipation, vaginal delivery, and FAMILY Hx (2.5 x) of
POP.
urethral hyermobility is defined as straining the Q-tip angle > 30 degrees from
horizontal. Retropubic urethropexy and other sling procedures are the surgical
treatment options.
Colpoclesis is an option to treat uterine prolapse.
For patients with intrinsic sphincteric deficiency, urethral bulking procedures are
minimally invasive and have a success rate of 80% in these patients. Slings and
needle suspensions are 2nd line. Artificial sphincters are used as a last resort.
Intrinsic sphincter deficiency - constant leakage of urine and description of a
"drain pipe" urethra.
Overactive bladder = destrusor instability. Treat with anticholingergics Oxybutynin
and Tolterodine
Central and lateral cystoceles are repaired by fixing defect in the pubocervical
fascia or reattaching to the side wall (archus tendineus fascia or white line).
Rectoceles are repaired by fixing defects in the rectovaginal fascia.
Uterine prolapse is surgically treated by hysterectomy.
Enteroceles are repaired vaginaly or abdominal repairs. Vaginal vault prolapse is
treated by supporting the vaginal cuff to the uterosacral or sacrospinous ligaments
or by sacrolpopexy.
Constantly leaking urine with a low PVR = Urge incontinence
No need to treat asymptomatic prolapse.
Colpoclesis closure of the vagina is the surgical choice when a woman (elderly)
presents with severe vaginal prolapse that needs immediate attention. Etc
hydronephrosis from the prolapse.
When treating pelvic prolapse go from least invasive to most invasive. Try
pessaries and other conservative measures first before going to surgery.

Endometriosis
The typical symptoms of endo are the 3 Ds: Dysparenuia, Dysmenorrhea, Dyschezia
(straining with bowel movements), Infertility, and chronic pelvic pain. Also,
nodularity along the back of the uterus along the uterosacral ligaments is
suggestive of endometriosis.
Adenomyosis presents with a boggy uterus.
PMDD (Premenstrual Dysphoric Disorder) is a condition in which a woman has severe
depressive symptoms, irritability, and tension before menstruation.
Endometriosis is present in 30% of infertile women.
Treatment of Endo goes 1) OCPs and NSAIDS if they fail this then 2) Ex lap with
Laser ablation or exicision of implants. 3) TLH/BSO
Danazol is a synthethic androgen used to treat endo but has many androgenic side
effects: body hair acne.
OCPs are way better for Endo. Don't use IUD.
Endo can only be diagnosed with a biopsy/visualization from an ex lap.
Sudden onset of pain and nausea and a cyst finding on ultrasound suggest torsion.
Once you think u have torsion ie clinical findings seem obvious next best step is
EX lap to detorse. Remember doppler ultrasound is the gold standard for diagnosis.

Someone with endo is having a hard time becoming pregnant, first try stimulating
them with Clomiphene citrate with or without intrauterine insemination.

Chronic Pelvic Pain

Someone with chronic pelvic pain who has not responded to OCPs or NSAIDs, may have
endo so diag lap is the next best step.
Interstitial Cystitsi is a chronic inflammatory condition of the bladder that
presents with recurrent irritative voiding symptoms: urgency and frequency. It is a
diagnosis of exclusion. It also presents with pelvic pain.
IBS - change in bowel habits in a chronic relapsing pattern of abd and pelvic pain
and bowel dysfunction. IBS is associated with chronic pelvic pain. Dx by rome
criteria you need at least 12 weeks in the last 12 months of abd discomfort or
pain that comes 2/3 features: 1) relief with defecation 2) onset associated witha a
change in freq of stool, 3) onset associated with a change in stool appearance.
GnRH agaonists work by downregulating the hypo-pit- axis. Recall you need pulsatile
release of GnRH for LH and FSH stimulation.
Danazol suppreses midcyle surge of LH and FSH.
Combined OCP estrogen and progesterone create a pseudopregnancy state.
Sexual abuse, and partner violence/strife is associated with pelvic pain. 40-50% of
women with chronic pelvic pain had a history of abuse (physical or sexual)
For a lady close to menopause, suffering from pain from endo - TLH and BSO is an
appropriate treatment option.
An old menopausal lady, has vague urinary, GI complaints, and post-menopausal
bleeding. Next best step is ultrasound --> then endometrial biopsy
A woman underwent Hysterectomy and is now Is having chronic pelvic pain and
symptoms related to the cuff. She has PELVIC adhesive disease.
A woman underwent BSO and is now having cylic pelvic pain. She has ovarian remnant
syndrome.
Pelvic congestion syndrome is a cause of chronic pelvic pain from PELVIC
varicosities. This pain is worse pre-menstrually andduring pregnancy and is
aggravated by standing, fatigue, and having sex. IT is described as pelvic
fullness or heaviness.
The iliohypogastric nerve provides cutaneous sensation to the groin and the skin
overlying the pubis.
The ilioinguinal nerve provides cutaneous sensation to the groin symphisis, labium
and upper innre thigh. These nerves can be injured by a low transverse incision
extended beyond the lateral border of the rectus abdominus muscle.
Damage to the obturator nerve causes the inability to adduct the thigh.

Disorders of the Breast

Age and gender are the greatest risk factors for developing breast cancer.
You should have a high suscipicion of BRCA when a 1st degree family member develops
cancer before age 50
A tender lymph node points at infection. A painless lymph node is more concerning
for cancer.
Someone comes in with nipple discharge, you measure a prolactin and it is
unequivocal. Slightly elevated. Your next step is to repeat it as there are many
things that can elevate a Prolactin level. Like stimulating a breast during a
physical exam. Accurate prolactin level should be measured in the fasting state
after no breast stimulation for 24 hours. After accurate measure of prolactin
levels, check TSH and a brain MRI for pituitary tumor.
Post-partium women can continue to produce milk for up to 2 years after stopping
breast feeding.
Fibrocystic changes are the most common cause of breast pain in women of
reproductive age. Caffeine intake can worsen this pain so they should drink less
coffee. Diet or alcohol has nothing to do with fibrocystic change.
FNA of a nipple mass produces bloody fluid. Your next step is excisional biopsy of
the mass. Why because blood suggests Cancer.
If the FNA of a nipple mass produces clear fluid then you can rexamine the mass in
2 months to check that the cyst has not reccurred.
For puerperal mastitis- treat with Dicloxacillin and the give the woman NSAIDS
(ibruprofen) and acetaminophen (Tylenol) for pain control. She SHOULD continue to
breast feed.
A breast mass that persists after FNA needs biopsy.
You can use breast MRI in addition to mammography in patients with an increased
risk of breast cancer: BRCA mutation, Li fraumeni syndrome, > 20% lifetime risk,
hx of radiation to the best from age 10 - 30, family history of breast cancer in a
1st degree relative
A woman comes in with a dominant breast mass. Mammogram is normal. What should you
do? Aspriate that lump. A normal mammogram does not rule out breast cancer.
Nipple itchiness is most commonly caused by chemical irritants: laundry detergents,
soasp, perfumes etc. Nipple itchiness can be a sign of paget's but you
would also see skin changes and should check for an underlying malignancy.

Gynecologic Procedures
A lady is found to have CIN 3 on pap/colpo but not ECC issues. Your next step is
LEEP.
IF a patient has invasive cervical carcinoma 1a2 - 2a then you can peform a radical
hysterectomy.
For Post-menopausal bleeding algorithm goes 1) Endometrial Biopsy +/- ultrasound
2) Hysterectomy or ablation if indicated.
1 of the complications of LEEP is infection, bleeding, cervical stenosis,
persistent disease, and PRETERM-delivery from cervical insufficiency.
Genital warts (condyloma acuminata) are treated with Trichloretic acid and imiquod.

A vulvar lesions that looks like a genital wart that is not responsive to treatment
needs to be biopsied.
If you can't remove an IUD with strings, next step is Hysteroscopy to remove it
under direct visualization.
If U/S showed the IUD was not in uterus, then you order an abdominal flat plate x-
ray. If U/S showed the IUD outside the uterus then you would do diag lap.
Again, woman presents with a mass, mammogram is normal. Next step is FNA for
cytology (exicisional biopsy gives you histology. Normal mammogram does not
rule/out breast cancer.
Someone presents with an incidental adnexal mass. Next best step is ultrasound to
evaluate.
Before prescribing anyone an IUD or contraception, ensure that they are not
pregnant. Other contraindicaitons are: personal history of breast cancer, hx of
thromobosis, history of liver tumor sor disease, and unexplained vaginal bleeding.

Someone has a polyp sticking right out of the cervix. Your next best step is to 1st
BIOPSY and then polypectomy.
Definitive treatment for Endo is TLH and BSO.

Puberty
Tits, Pits, Mitts, Lips Thelarche comes before adrenarche, then a growth spurt,
and then menarche. 8 - 11
A body weight of 85 - 106 is needed before menses begin. A girl weighing 80 pounds
hasnt had menses yet. It's because of her weight,
Sleep and exposure to sunlight are important for development of secondary sexual
characteristics.
Turner syndrome can be a cause of lack of secondary sex characteriistics and
Primary amenorrhea.
A 16 year old girl presents with no 2 sexual characteristics but normal external
genitalia. You suspect Kallmann's. How do you diagnose olfactory challenge- They
don't have a sense of smell (anosmia)
True precocious puberty is a diagnosis of exclusion where the sex steroids are
increased by the hypothalamic pitutiary gonadal axis with increased pulsatile GnRH
secretion.
CAH presents in the neonatal period and is associated with ambiguous genitalia.
McCune Albright syndrome is characterized by premature mesnes before breast and
pubic hair development. An ovarian neoplasm is unlikely with a normal pelvic
ulstrasound.
CAH of the 21 hydroxylase type results in accumulation of adrenal androgens leading
to precocious adrenarche. Treament is give the patient steroids.
A girl is positive for 2 sex characteristics but primary amenorrhea. pElvic u/s
shows blind pouch, no uterus but positive for ovaries. - Next step is check her
kidneys. Renal anomalies occur in 25-35% of females with Mullerian agenesis.
A 13 year girl complains of cylic abdominal pain that gets worse at one particular
time every month but hasn't started her menses yet. She has an imperforate hymen.
Ashermann syndrome is 2nd amenorrhea from intrauterine scarring/synechiae.
A 15 year old girl complains of not having a period but she is sexually active.
What should your next step be. Order a urine pregnancy test.
Bluish color to the cervix is Chadwick's sign- caused by increased blood flow to
the cervix which is an indication of pregnancy.
HPV vaccine should be offered to females b/w the ages of 9 and 26. A 12 year old
comes in for a visit. Mom complains that she has not had menses yet. Reassure and
counsel to get HPV vaccine.

Amenorrhea
24 year old clllege student, 2 amenorrhea, low weight --> Hypo-Pit dysfunction due
to low weight/eating disorder.
Can diagnose Hypo-pit dysfunction by measuring FSH levels.
PCOS: oligomenorrhea, hirsutism --- 1) weight loss and exercise 2) OCPs so they are
not exposed to unopposed estrogen
32 year old woman, Amenorrhea for 3 months, woman is sexually active, a slightly
enlarged uterus - think pregnancy
New onset dyspareneuria, amenorrhea for 12 months, normal prolactin and TSH in a 33
year old G0. Likely Premature Ovarian failure.
Imperforate hymen is treated surgically.
Hypo-pit dysfunction from excessive exercise falls under HYPOTHALAMIC amenorrhea.
Woman with a history of abortions requiring D and C now presents with amenorrhea.
Likely from Ashermann's or intrauterine synechiae (adhesions). Adhesion tissue
replaces the basalis layer.

Hirsutism and Virilization

Hirsutism in setting of elevated DHEAS and normal testosterone - Think an Adrenal
tumor
Asians with PCOS are less likely to present with Hirsutism.
18 year old presents hirsutism and acne and irregular periods. TSH, Proalctin, and
testosterone and DHEAS are normal. YOU should order 17-hydroxyprogesterone to rule
out late onset 21-hydroxlase deficiency.
PCOS- testerone is ususally elevated.
To diagnose cushing, order a 24 hour-urinary measurement of cortisol or overnight
dexamethasone suppression test.
Careful for late-onset 21 hydroxylase deficiency
Acanthosis nigricans is associated with elevated androgen levels and
hyperinsulinemia (diabetes).
Post-partum telogen effluvium (hair loss) affects 40-50% of women postpartum. High
estogen levels increase the synchrony of hair growth ie hair grows in the same
phase and is shed at the same time. This can result in significant post-partum
hair loss at 1- 5 months pospartum.
Post-partum hair loss is normal.
Woman who is not pregnant presenting signs of virilization: acne, hirsutism,
amenorrhea, clitoral hypertrophy, and deepening of her voice and has a right
adnexal mass - think sertoli-leydig tumor producing testosterone. Common in women
age 20-40, usually unilateral. You can see suppression of FSH and LH by all the
testosterone. Next step is pelvic ultrasound.
Granulosa cell tumors and thecomas are estrogen-secreting tumors.
Hyperthecosis is a MORE severe form of PCOS. It is associated with virlization due
to high androstenedione production and testosterone levels. Signs include Temporal
balding, clitoral enlargement, and deepening of the voice. It is more difficult to
treat with oral contraceptive therapy.
Spironolactone, an aldo/androgen antagonist is a good treatment for hirstuism.
You would not used Danazol since it is an androgen analogue.
OCP for PCOS patients can treat both the amenorrhea and treat hirsutism symptoms.
OCPs increase the amount of sex-binding globulin which bind the extra testosterone
reducing some of the hirsutism symptoms.

Normal and Abnormal Uterine Bleeding

Progestins work by converting the endometrium from prolfierative to secretory. Then
withdrawal of progesterone causes sloughing of the endometrium or menses.
Grown woman of reproductive age, G3 presents with AUB, next step is pelvic
ultrasound to look at her endometrial stripe or look for polyps of submucosal
fibroids or adenomyosis.
Young girl 14, just started menses and is having AUB - think of a clotting disorder

VonWille brand is the most bleeding disorder. Factor 5 leiden is the most common
blood clot disorder.
Fibroids usually develp in 30s - 40s.
Management of polyps If the polpy is > 1.5 cm then you cannot just OBSERVE you
have to treat. In women with infertility, do polypectomy. Medical management
with progesting and curretage are other treatment options.
Any young woman coming in with bleeding, don't forget to order the pregnancy test
to rule out an ectopic.
Functional cyst is a common finding in ovulatory patients.
Hysteroscopic myomectomy is the best way to preserve fertility to remove a
SUBMUCOSAL fibroid.
Patients over 35 and who SMOKE should not be given OCPs.
Transplant patients are at increased risk of cervical dysplacia because of
immunosuppressive medications.

Sexual Assault
Children who are sexually abused will act out and behave inapporpriately. Often
no evidence of physical injury.
Asperger's is a syndrome of autism spectrum disorder with problems with social
interaction with physical clumsiness and atypical use of language.
Children can get yeast infections (especially after abx of an ear infection) which
would present with vaginal discharge and swelling of the vulva possible from
excoriations. Scratching of the vulva can mimic child abuse but the vaginal
discharge is a tip off of a yeast infection.
If a foreign body is suspected in a young girl, then proceed with an exam under
anesthesia.
A 28 year old women presents with a serious vaginal tear and gives an excuse of
trying out a new sex toy. BP is stable but she is slightly Tachy. Next best step is
repair the laceration under anesthesia.
Rape is characterized as lack of consent or inability to give consent ie the girl
is under 16.
After someone is rape ensure you get forensic specimens, notify police, get
cultures for GC/Chlamydia and blood test for Syphillis and HIV. Can give
Ceftriaxone and Doxy prophylatcially as well POSTexposure prophylaxis for HIV.
When someone is raped, make sure you ask if they have had sex with anyone else
recently as you're taking forensic samples.
Following sexual assualt, a woman should NOT shower, change or brush her teeth, and
should go to the ED. So a history can be taken, physical done, and forensic test
taken, police notified. And then she can be tested for diseases and treated
prophylactically and offered emergency contraception. Also, give her a pregnancy
test!
Any STI testing done right after a rape is to establish her current STI status. If
she contracted any diseases from her rapist, it won't show up until several weeks
later. Same with the pregnancy test.
All women should be offered emergency contraception after sexual assualt regardless
of any conditions ie rapist used a condom etc
Plan B is effective for 3 days. Ella (Ullipristal) is effective for 5 days.

Domestic Violence
Intimate partner violence outreach information such as numbers to call for help
should be placed in a private place like the bathroom.
Notify CPS/social services for elder abuse.
If a someone experiencing intimate partner violence is not ready to tell you the
truth, all you can do is give them IPV resources. It is their decision if they want
to call the police, get social work/social services involved etc.
Reproductive coercion is a form of IPV. Man won't let the woman decide if she wants
to be pregnant or not. Give IPV resources.
You are not required to report IPV to the police. Don't force resources on patients
either. All you can do is offer it to them.

Sexuality and Modes of Sexual Expression

If a child confides that she is sexually active and is using contraception. You are
not obligated to the tell her mother. You can tell the mom, your daughter is
healthy.
vaginal atrophy usually causes insertional dysparenuria. Use vaginal estrogen and
water-based lubricants.
Deep dysparenuria is associated with pelvic inflammation like endo or prior pelvic
surgery.
Urogenital atrophy is the most common cause of insertional dysparenuria in post-
menopausal women. Being thin can make atrophy worse since they have less estrogen.

lubrication during the arousal phase of intercourse is most dependent on transudate

of fluid across the vaginal mucosa.
sexual behavior describes how a person chooses to act sexually. It is independent
of sexual orientation (who a person is attracted to) or gender identity (the gender
a person idenfifies with).
Gender dysphoria is when in your mind you feel you are the opposite of your
biological sex.
Treat vaginimus with dilators. Vaginismus is involuntary constriction of vaginal
musculature that makes coitus painful or impossible. Perpetuated by a cycle of
anxiety and pain.
sensate focus treats sexual arousal disorders.
Low libido post-partum is actually normal. It can be from stress and disruption of
having a newborn, hyperprolactinemia and hypoestrogenism, perineal pain. Tx by
giving reassurance that this normal.
Flibanserin is indicated for premenopausal hypoactive sexual desire disorder.

Dysmenorrhea
1st line of treatment for Dysmenorrhea is OCP. If you inhibit ovulation, should
improve the pre-menstrual symptoms and cramps.
Progestin in OCPs causes endometrial atrophy. Less endometrium= less
prostaglandins produced = less cramping.
All women 25 and younger should get Chlamydia and Gonorrhea testing.
Dymenorrhea unresponsive to OCPs warrants workup for Endo - so Diag lap. Can also
look for pelvic adhesions.
Progesterone-IUD is 1st line for treating adenomyosis because it renders the
endometrial tissue into the secretory phase all the time. If it cant grow in the
myometrium then no pain.
Endometriosis is a form of secondary dysmenorrhea meaning that another issue causes
the dysmenorrhea. Others include adenomyosis, fibroids, infection etc.
Pre-menstrual symptoms only occur in the luteal phase of the cycle. Adeno is more
likely to occur in multiparous women.
For fibroids, GnRH can be given to shrink fibroids but this not definitive
treatment. Hysterectomy is definitive.
Any women over the age of 40 with irregular bleeding should get an endometrial
biopsy.
On pathology, well-circumscribed, non-encapsulated myometrium confirms the
diagnosis of fibroids.
Hyperplastic overgrwoth of endometrial glands/stroma = endometrial polyps
Invasion of endometrial glands into the myometrium is seen with adenomyosis.
Polpys are common in women age 40 - 50 and can cause increased menstrual flow,
increased cramping, and intermenstrual spotting.
Subserosal fibroids do not cause dysmenorrhea while the other forms can.
NSAIDS are first line for dysmenoorhea. Of course you follow this with OCPs but are
contraindicated by DVT.

Menopause
Perimenopausal woman with unexplained AUB cannot be given HRT. Why well that
abnormal uterine bleeding could be from endometrial carcinoma so don't give HRT
Any women over 40 with AUB, you do an endometrial biopsy.
Menopasual women should take 1200 mg of Calcium per day and 800-1000 units of
Vitamin D.
One of the risk factors for osteoporosis in menopausal women is history of fracture
as an adult, low body weight, and being a current smoker. Menopausal women < age
65 who have a fracture should get a DEXA scan and start getting treatment with
Bisphosphonates and Caliucm supplementation.
Short-term HRT is the most effective treatment for severe menopausal symptoms.
Only offer vaginal estrogen is the vaginal dryness is a problem for the patient. If
lube alone works no need for treatment.
HRT used at the lowest possible dose for the shortest amount of time. If she has a
uterus e+p. No uterus, can use e alone.
HRT is the most effective for treating hot flashes and other menopausal symptoms.
Menopausal ovaries still make androgens but stop making estrogen. This siwhy
Ophorectomy can bring back menopausal symptoms. You reduce circulating androgens
which are normally still conveted into small amounts of estrogen by fat cells
peripherally.
HRT increase the risk of breast cancer (if E+P does not increase uterine cancer)
and reduces risk of colon cancer. Believed progesterone might explain increased
risk of breast cancer.
HRT (estrogen) is protective against bad cholesterol. It improves your serum lipid
profile. *reduce LDL and increased HDL.
If a menopausal woman is dexa-scan positive y ou also have to consider her risk of
fractures: this includes: personal history of fracture, family history of
osteoporosis, being White or Asian, dementia, and history of falls, and smoking and
alcoholism.

Infertility
Clomiphene, Progesterone levels, and cervical mucous are all ways to check for
ovulation.
Hyperprolactinemia can be caused by anti-psychotic agents as they are Dopamine
antagonist (Detour back to reality).
For exercise-induced hypothalamic amenorrhea, if you measure low to normal FSH and
LH, your next step is to check estrogen levels.
IF there is concern that an older woman has decreased ovarian reserve, then you can
order Anti-mullerian hormone. AMH is made by granulosa cells in primordial
follicles. Lower AMH = Less primordial follicles so the woman has reduced ovarian
reserve.
Ovulation predictor kits are the best thing to use when trying to maxmize chances
of pregnancy.
Always blame the male first for infertility.
Treat PCOS with weight loss and exercise, metformin, spironolactone, and Clomiphene
if she wants to become pregnant.
Remember hypothryroidism leads to hyperprolactinemia which causes inferility. TRH
stimulates Prolactin release.

Pre-menstrual syndrome
1st line treatment for someone complaining of premenstrual syndrome is have them
keep a diary. This lets you know if the onset of symptoms in the luteal phase or
before her periods start so you can truly say it's premenstural syndrome.
PMS and Premenstrual dysphoric disorder (PMDD is the more severe form). 1st line
treatment is OCP to suppress hormone levels.
Careful hypothyroidism causing mood issues, fatigue, and bloating can present like
PMS. If the patient says she has this everyday or it's outside the luteal cycle
think Hypothyroidism.
Bilateral oophorectomy is a last resort for women with severe MPDD that is
refractory to other treatment options. You can tell if this will work by giving the
woman GnRH agonist . It simulates a MENOPAUSE like state.
SSRI can be used to treat PMS and PMDD. Take the med every day or only during th
luteal phase.
Endorphins released from exercise can help with PMS and PMDD symptoms.
RF for PMS include a family history, Vitamin B6 or magnesium deficiency.
Someone with the typical PMS ie bloating, mastalgia, cramping, can be treated with
an NSAID as 1st line.
1200 mg of calcium can help to improve PMS symptoms. (also giving B6 (pyroxidine
and Vitamin E) can be helpful.

Gestational Trophoblastic Neoplasm (GTN)

Asian women are at increased risk for molar pregnancy. They occur more in younger
patients < 20 or older patients > 40. Lower intake beta-carotene and folic acid is
also a risk factor. Women with 2 or more miscarrages are also at increased risk.
The recurrence risk of a molar pregnancy is 1-2%, which 20 fold greater than the
population (background) risk.
Uterus with a snowstorm appearance on ultrasound = complete mole Due to the
multiple hydropic villi.
Vaginal bleeding occurs in every molar pregnancy, can also have size-date
discrepancies.
Complete mole = no fetal parts. Partial mole = Has fetal Parts.
B-HCG > 1 million is diagnostic of a molar pregnancy. The mom may be tachycardic
due to alll of the B-HCG causing hyperthyroidism. HTN from preeclampsia.
whenever anyone comes in with vaginal bleeding and amenorrhea, B-HCG first then
follow with Ultrasound. ALWAYS.
You treat molar pregnancies with Suction Curettage.
MTX can be used for post-molar GTN.
Partial moles have 69 chromosomes and a lower risk of developing GTN. Present with
lower B-HCG levels, affect older patients, have longer gestations, and often
diagnosed as missed or incomplete abortions.
Complete moles ususally present with larger uteri, preeclampsia, and higher
likelyhood of developing into post-molar GTD.
People with moles should wait 6 months after neg BHCG testing before trying to get
pregnant again. Give the patient OCPs so that you can follow and ensure that B-HCG
levels are low.
In people with moles who seem to have possible mets, like the woman with a mole has
a friable lesion in her vagina you should stage them with CT scan of the chest,
abd, and pelvix. Brain MRI.
To treat persistent GTN disease give chemotherapy. MTX can be given to patient who
will be lost to follow-up.
B-HCG iin a woman with a recent pregnancy (term, miscarraige, termination, mole) is
used to diagnose Choriocarcinoma. You don't need a tissue biopsy.
You should not biopsy lesions suspcious for choriocarcinoma since it is very
vascular.

Vulvar Neoplasms
Lichen sclerosis has a risk of becoming SCC.
Whenever you see any lesion on the vulva your first step is biopsy. You can't do
surgery without first getting a biopsy.
For SCC and melanoma in the vulva area, you treat aggressively. Radical vulvectomy
and groin LN dissection.
For paget's disease you can treat more conservatiely, wide-local excision.
SCC makes up 90% of all vulvar cancers.
Paget's disease of the vulva is associated with white-plaque-like lesions and
poorly demarcated erythema. Not a discrete mass. Erythematous with a lacy white
mottling of the surface.
Melanoma presents as a pigmented lesion. ABCD (asmmetry, irregular borders, color
is variegated (multi) dimater >
Old lady 74 years old, mass near the Bartholin gland - Think Bartholin gland
maligancy.
What do you do for VIN 3. Wide local exicison since this a "superficial lesion and
is not yet cancer" You do not do Radical vulvectomy and groin LN dissection
Women on immunsuppresive therapy ie LUPUS meds, are at higher risk for HPV related
infections such as condyloma or vulvar dyspalsia (VIN).
For VIN2 think laser treatment to burn off those bad boys.
fiery red mottle background with whitish keratotic areas = Paget's disease of the
vulva description
RF for SCC of the vula are HPV exposure, smoking, lichen sclerosis,
immunocompromise.

ASCUS next steps are repeat PAP in 1 year or HPV testing in 6 months.
You see any lesions on the cervix, biopsy it. IF you think someone has cervical
cancer then you don't do a pap smear or colpo. You go str8 to biopsy.
Microinvasive cancer = cancer that invade less than 3 mm past the basement
membrane.
Positive ECC on colpo - you need cold knife conization

Fibroids
The most common symptom associated with fibroids is heavy menstrual bleeding - due
to submucosal fibroids which increase the size of the uterine cavity (greater
surface area) 2) exerts pressure on the uterine vasculature. Patients also feel
pain and pressure, presure against the bladder, bowel, and pelvic floor.
Fibroids are very common 80% of women have them and are often asymptomatic.
Pregnant women with fibroids are usually asymptomatic and do not have any
complications from the fibroids. But in some cases a fibroid in the lower uterine
segment can cause tissue dystocia requiring a C-section.
You cannot due MYOMECTOMY of any sort during pregnancy and you should not do it
immediately after delivery due to the risk of increased blood loss.
Submucosal fibroids distorting the uterine cavity are an infrequent cause of
miscarriages. They can also obstruct the fallopian tubes. Tx submucosal fibroids
by hysteroscopic resection.
Only treat fibroids if they are symptomatic.
Bariatric surgery is only considered when a woman has a BMI > 40 or 35-39 with
serious weight/health problems ie T2DM, HBP, or sleep apnea.
Irregularly enlarged uterus = fibroid
Any women over 40 with AUB, your best next step is always endometrial biopsy.
When treating fibroids start of with NSAIDS and OCPs. But then move on to a GnRH
agonist to try to shrink the fibroid.
UAE is contraindicated in a woman who wants to maintain her fertility.
GnRH achieves its maximal response by 3 months. The reduction in size correlates
with estradiol level and body weight. Hot flashes are experienced by > 75% of
patients. When you stop the GnRH, menses return in 4 - 10 weeks and the fibroid
grows back to its pretreatment size in 3-4 months.
Leiomyosarcomas occur in post-menopausal women. Uterine fibroids (leiomyomas)
occur in reproductive aged women.
Adenomyosis = symmetrical enlarged, boggy uterus and presents with dysmenorrhea and
heavy menstrual bleeding.
If a young woman with fibroids desire fertility, myomectomy is the WAY to go.
If a woman has a new onset pelvic mass regardless of she is asymptomatic or if it
sounds like fibroids, you have to at least work it up with pelvic/tv ultrasound to
confirm that it is a fibroid.

Endometrial Carcinoma
The finding of Complex Atypical hyperplasia on endometrial biopsy is very
concerning and gives a 30% chance that the woman has endometrial cancer.
Obesity, nullparity, late menopause, HTN, DM, tamoxifen treatment and exposure of
unnopposed estrogen are risk factors for endometrial carcinoma.
If a 69 year old woman comes to you and she has no vaginal bleeding or discharge or
other symptoms physical exam is normal and she says I am worried about endometrial
cancer. What do you? You just reassure hre.
Endometrial Carcinoma presents first and foremost with post-menopausal vaginal
bleeding .But it can also present with vaginal discharge or lower abd discomfort.
HRT combo does not increase the risk of endometrial cancer. Taking only Estrogen
HRT increases the risk of endometrial cancer.
A woman has a positive endometrial biopsy for Endometrial Adenocarcinoma. The next
best step is go straight to the OR to do a TLH and BSO.
IF the endometrial biopsy said Complex Atypical Hyperplasia then you can repeat
biopsy to see if there reall is cancer. But once you see cancer once, it's time for
uterus to come out.
Granulosa cell tumors make estrogen which can then lead to endometrial hyperplasia
and carcinoma (unopposed estrogen stimulation).
The most common cause of post-menopausal bleeding are 1) atrophy of
endometrium/vagina 2) HRT 3) Endometrial cancer 4) Polyps 5) hyperplasia
Pelvix U/S with a stripe < 4 mm still does not rule out the possiblity of
endometrial cancer. If the woman is >40 and has vaginal bleeding then do the
biopsy.
If a post-menopausal woman comes in with vaginal bleeding and endometrial cancer is
r/o by biopsy and u/s, then she probably has bleeding from vaginal atrophy so give
her vaginal estrogen.
Spiral fractures, new and old bruises, etc in an elderly patient should raise flags
for elder abuse. Spiral fractures are a HUGE buzz word as they result from
twisting of the arm.
The most common places for osteoporotic fractures are the vertebrae, hip, and
wrist.

Ovarian Cancer
The risk factors for Ovarian cancer are nullparity, family history, early menarche,
and late menopause and white race. Anything that increases the amount of ovulation
trauma that occurs to the ovaries.
Unilocular simple cyst in a reproductive aged woman is likely to be a functional
cyst. Functional cysts are normal so no needed to anything. Reassure.
Dermoid cysts or tumor tend to have solid components, appear echogenic on u/s,
contain teeth cartilage, bone, fat, and hair.
Pelvix mass, abd bloating, abd fullness are all buzzwords for Ovarian cancer.
When someone is diagnosed with ovarian cancer with an elevated CA-125 and clinical
signs what's next? Stage with CT of the abd and pelvix. You want to look for
omental caking.
PET-scan has no role in staging of Gyncologic diseases but can be used to follow
recurrence.
Granulosa cell tumor which is a sex cord stromal tumor secretes estrogen. Most
commonly affect women in their 50s.
Germ cell tumors affect women of younger age Age 10 -30.
Epithelial surface tumors account for 90% of al lcancers and typically occur in
the 6th decade of life.
Krunkenberg is metastatis GI cancer.
Remember, young female, presents with vaginal bleeding or discharge. Abd pain,
tenderness on exam, oligomenorrhea --> Ectopic pregnancy.
Prognosis is based on Tumor stage - how far has this tumor spread.
If a woman has advanced ovarian cancer ie has spread. Step 1) Debulking surgery
Step 2) Adjuvant chemotherapy with a taxane or platinum. 5 year survival for Stage
3 is 30%.
30 year old with an ovarian mass likely has a dermoid tumor because of her age.
Low parity and delayed child-bearing can increase the risk of ovarian cancer.
Long-term suppresion of ovulation is protective against the development of ovarian
cancer.
Women with Known BRCA mutations may considered prophylatic Salpingo-ophorectomy.

If you have a 1st degree relative with colon cancer befor the age of 60, then
colonscopy can begin at age 40 or 10 years before the relative was diagnosed.
RF for osteoporosis: 1) Family history 2) age > 50, 3) Gender: women are 4x more
likely than men 4) Skinny women are at increased risk (less weight bearing and less
estrogen) 5) Excessive Alcohol consumption increases the risk.
All women of reproductive age should take folate!

Legal Issues and Ethics

In cases where the life of the patient or fetus is at risk, informed consents are
not need for life-saving measures.
A woman comes in and says I want a C-section but she wants 5 kids. Even if there
are reasons to recommend vaginal delivery it's her choice. You schedule a C-section
at 39 weeks.
You cannot schedule elective C-sections until 39 weeks.
Patient privacy is the responsibility of all health care providers.
A doctor says well this ancephalic baby won't live anyway. Even if it goes into
distress I won't do a C-section to put the mother at risk. This is non-malificence
to the MOM. Do no harm to the mom.
An alive and mentally intact patient trumps the power of attorney.
A power of attorney should make decisions based on what the PATIENT would have
wanted for herself, regardless of the doctor's recommendations or family member's
wishes.
A physician can own stock in whatever project they are researching as long as they
disclose. Pharamceutical companies can suppor the costs of medical conferences
where physicians receive continuing medical education credits.
Patients requesting abortion should be counseled even if they don't have insurance.
The decision for abortion is the woman's alone!
Race - black and hispanic more likely to be uninsured. Men are more likely than
women to be uninsured.