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OB-GYN - Shelf Review Notes PDF
OB-GYN - Shelf Review Notes PDF
Table of Contents
Obstetrics.......................................................................................................................................................................................................2
Normal pregnancy / Prenatal care............................................................................................................................................................2
Early Pregnancy Complications..................................................................................................................................................................4
Prenatal Screening...........................................................................................................................................................................................5
Normal L&D........................................................................................................................................................................................................7
Antepartum Hemorrhage..............................................................................................................................................................................9
L&D Complications........................................................................................................................................................................................10
Fetal complications of pregnancy...........................................................................................................................................................11
Hypertension & Pregnancy........................................................................................................................................................................13
Diabetes in pregnancy.................................................................................................................................................................................14
Infectious Diseases in Pregnancy............................................................................................................................................................15
Infections that can affect the fetus (TORCH, etc)........................................................................................................................16
Other Medical Complications of Pregnancy........................................................................................................................................17
Postpartum care / complications............................................................................................................................................................19
Gynecology................................................................................................................................................................................................21
Benign Lower Genital Tract Disorders..................................................................................................................................................21
Benign Upper Genital Tract Disorders..................................................................................................................................................23
Endometriosis / Adenomyosis.................................................................................................................................................................24
Lower reproductive tract infections......................................................................................................................................................25
Upper reproductive tract infections.......................................................................................................................................................27
Pelvic organ prolapse...................................................................................................................................................................................28
Urinary Incontinence...................................................................................................................................................................................29
Puberty...............................................................................................................................................................................................................30
Menopause.......................................................................................................................................................................................................30
Amenorrhea.....................................................................................................................................................................................................31
Menstrual cycle abnormalities.................................................................................................................................................................32
Hirsutism & Virilization..............................................................................................................................................................................33
Contraception / Sterilization....................................................................................................................................................................34
Elective Termination of Pregnancy........................................................................................................................................................35
Infertility and Assisted Reproductive Technologies........................................................................................................................36
Vulvar / Vaginal Neoplasia........................................................................................................................................................................38
Cervical Neoplasia / Cancer.......................................................................................................................................................................39
Endometrial Cancer......................................................................................................................................................................................40
Ovarian Tumors..............................................................................................................................................................................................41
Gestational Trophoblastic Disease..........................................................................................................................................................43
Breast Disease & Breast Cancer...............................................................................................................................................................45
Benign breast disease............................................................................................................................................................................45
Malignant breast disease:.....................................................................................................................................................................46
Other random stuff........................................................................................................................................................................................47
Obstetrics
Normal pregnancy / Prenatal care
● Urine preg test: positive around time of missed cycle.
○ Gestational sac on transvag U/S @ b-hCG of 1500-2000 (5wks)
○ Fetal heart @ b-hCG of 5-6000 (6wks)
● TPAL: remember abortus = < 20 wk losses (TAB/SAB/ectopic)
Physiology of pregnancy:
● CV:
○ CO increases 30-50%, most in 1st trimester, SV first, then HR.
○ SVR decreases (BP falls) 2/2 progesterone, nadir @ wk 24 (then volume increases catch up)
● Pulm: Tidal volume increases (bigger breaths, horizontal expansion), TLC decreases (diaphragm
elevated), respiratory rate stays the same, but minute ventilation increases (2/2 tidal volume increase),
○ so PaO2 increases, PaCO2 decreases (30 mm @ 20 wks), helping baby get oxygen
● GI:
○ N/V in first trimester, should resolve by 14-16 wks, otherwise consider hyperemesis gravidarum
(lose > 5% wt, go into ketosis), encourage frequent snacking.
○ Prolonged gastric emptying / GES tone lowered 2/2 progseterone = reflux
○ Decreased motility in large bowel = more water absorbed = constipation
● Renal:
○ kidneys bigger, ureters dilate → pyelonephritis
○ GFR increases (50%) early, 2/2 increased plasma volume, so BUN and Cr drop
● Heme:
○ Plasma volume increases 50% , RBC mass increases 20-30%, dilutional anemia
○ WBC increases to ~10.5, plts only drop a little (should be > 100)
○ Hypercoagulable state (more factors VII-X, fibrinogen) although INR/PTT stay the same
● Decreased oncotic pressure! Tocolysis with terbutaline can cause pulmonary edema (already
prediposed from decreased oncotic pressure)
● Endocrine: lots of estrogen from adrenal precursors converted in placenta.
○ hCG, LH, FSH, TSH all have same alpha subunit. hCG maintaisn corpus luteum in early pregnancy.
○ hPL ensures nutrient supply, diabetogenic
○ PRL increased during pregnancy
○ TBG increased by estrogen, so total T3/T4 increase but fT4 stays the same
○ Glucosuria is common in pregnancy!
Nutritional stuff
● Folate stuff:
○ 4mg/day folate if previous hx NTD, on carbamazepine or valproate, or pregestational DM
○ Otherwise 0.4-0.8 mg/day for all other women of “reproductive potential”
● Weight gain in pregnancy: don’t ever want to lose weight, just gain less if overwt.
○ Underweight (BMI < 18.5) → 28-40 lbs.
○ Normal wt (BMI 18.5-24.9) → 25-35 lbs.
○ Overweight (BMI 25-30) → 15-20 lbs
○ Obese (BMI > 30) → 11-20 lbs
○ Add 300kcal/day in pregnancy, 500kcal/day in breastfeeding.
Antenatal screening:
● First trimester (NT/ nasal bone on U/S and PAPP-A/free b-hCG bloodwork) @ 11-13 wks
○ Can do CVS around 9-12 wks if concerns, > 1:200 risk miscarriage
● Quad screen (MSAFP, b-hCG, estriol, inhibin A) @ 18-20 wks
○ Can do amnio after ~ 15wks if concerns, 1:200ish risk miscarriage
● Anatomy screening U/S @ 18-20 wks also.
● Glucose loading test @ 27-29 wks (earlier if multiples / hx).
○ GLT: 50g challenge, check in 1 hr, if 140 or more, go to OGTT
○ OGTT: 100g challenge, measure fasting and at 1,2,3h. Should be less than 95/180/155/140.
○ 6wk PP: 75g challenge, measure in 2 hrs.
BPP: 0 or 2 scoring for AFI, fetal tone, fetal activity, breathing movements, NST
● U/S with cord doppler if worried for placental insufficiency (decrease / reversal of flow)
NST: in 20 min, need 2 accels that are 15 bpm above baseline x 15 seconds
● U/S if worrisome.
Contraction stress test: get 3 ctx in 10m, analyse FHR
Prenatal Screening
Remember PPV = % pts with positive screen that are affected; NPV = % pts with negative screen not affected, +LR
and -LR tell you how to adjust pretest odds to get posttest odds
Remember, for an autosomal recessive disease, the sibling of an affect pt has a ⅔ chance of being a carrier.
● Example: Dad’s brother has sickle cell disease. Neither parent has been checked. Dad has ⅔ chance of
being a carrier; Mom has 1/12 (population risk), so risk for affected child is (1/2) x (1/12) x (1/2) x (2/3)
● Also remember Hardy-Weinberg: p2 + 2pq + q2 = 1 @ equilibrium where p, q = allele frequencies, p2 / q2 =
homozygotes, 2pq = heterozygotes
Cystic fibrosis: Aut-rec, CFTR gene, chloride channel, commonly deltaF508 / G542x but 1000+ mutations known
● sx: lung / cor pulmonale / pancreatic insufficiency / infertility
● 1/29 Caucasians are carriers; screen parents, then with CVS / amnio if both parents carriers (1/4 risk)
NTD High
● Down syndrome: flattened nasal bridge, small size, cup-shaped ear, sandal-gap toes, hypotonia, simian
crease, epicanthic fold, oblique palpebral fissures, protruding tongue, short, broad hands.
○ Higher rates of stillbirth, miscarriage. IQ 40-90. A/w duodenal atresia, cardiac defects, short
limbs, nasal bone hypoplasia.
○ echogenic intracardiac focus only has LR of 2.0, so at most doubles pretest odds.
● Trisomy 18 = Edward: Clenched fists, overlapping digits, rocker bottom feet, VSD / tetFal, omphalocele,
CDH, NTD, choroid plexus cysts. Fetal / neonatal death.
● Trisomy 13 = Patau. holoProsencephaly, cleft lip and Palate, cystic hydroma, single nostril, omphalocele,
hypoPlastic left heart, clubfoot / hand, Polydactyly, overlapping fingers.
● Turner syndrome = XO: wide-spaced nipples, shield-like chest, lymphedema, primary amenorrhea,
coarctation of aorta, short 4th metacarpal, receding hairline
● Klinefelter syndrome = 47,XXY. small, firm testes, hyalinized seminiferous tubules, infertility,
gynecomastia, MR, elevated gonadotropin levels.
Congenital anomalies:
● Organogenesis: wks 3-8 after conception (wks 5-10 EGA). Insult before = probably will lose pregnancy.
● Radiation during weeks 8-15 has greatest risk of fetal microcephaly / severe MR
● Neural tube defects: defective closure by 4 wks after conception (6 wks EGA). Need folic acid before!
○ Spina bifida, anencephaly, etc. Elevated AFP
○ Spina bifida: see lemon sign (concave frontal bones), banana sign (curved cerebellum) on U/S.
● Cardiac defects: follow with fetal echo, get peds cards on board. Week 3 (wk 5 EGA) is key time.
○ VSD: failure of ventricular walls to form
○ TetFal: overriding aorta, pulmonary stenosis, RV hypertrophy, VSD
○ Transposition of the great arteries (PA/ Ao into wrong vent)
○ Coarctation of the aorta: generally preductal if congenital
○ PDA → Eisenmenger syndrome
○ Hypoplastic left heart: worst outcome with surgery.
● Potter sequence: renal failure → anhydramnios → pulmonary hypoplasia / contractures.
○ From bilateral renal agenesis, but also if posterior urethral valves / extrophy with obstruction / etc.
○ Embryology:
■ Pronephros → degenerates.
■ Mesonephros (Wolffian duct) → gives off [ureteric bud → urinary collecting system
(tubules, calyces, renal pelvis, ureter)], then degenerates in females, turns into vas /
epidydimis / ejaculatory duct / seminal vesicles if T around in guys.
■ Metanephros → kidney
■ Paramesonephric duct (Mullerian) → Fallopian tubes, uterus, cervix, upper 1/3 of vagina
● Fetal anemia: If Rh isoimmunization, hydrops, other concerns for anemia, get PUBS (can get Hct /
transfuse too if needed!)
Normal L&D
Report to the hospital for suspected labor if any of these:
● contractions every five minutes for one hour
● rupture of membranes
● fetal movement less than 10 per two hours
● vaginal bleeding.
Breech presentation a/w prematurity, multiples, genetic disorders, polyhydramnios, hydrocephaly, anencephaly,
uterine abnormalities, uterine fibroids. ?oligohydramnios (Williams says it is, uWise says it isn’t)
Normal ROM: < 1h prior to onset of labor (>1h = PROM, >18h = prolonged PROM, if < 37wks = PPROM)
● Pool, nitrazine (amniotic fluid = alkaline), ferning tests to r/o ROM. Cervical mucus = false + fern
● Oligohydramnios in absence of other findings may suggest ROM too.
● If really need dx, can inject indigo carmine into amniotic sac → look for blue staining of tampon
Bishop score: measure cervical dilation, effacement, station (0-3) and consistency, position (0-2).
● Bishop > 8 = “favorable” for spontaneous labor / induced labor.
0 1 2 3
Position Posterior Intermediate Anterior -
Consistency Firm Intermediate Soft -
Effacement 0-30% 31-50% 51-80% >80%
Dilation 0 cm 1–2 cm 3–4 cm >5 cm
Fetal station -3 -2 -1, 0 +1, +2
Fetal monitoring: external or FSE (but not if fetal thrombocytopenia → bleed or HIV/HCV → transmission)
● Baseline 110-160 with moderate variability, +accels = good!
● Decels
○ Early = increased vagal tone (head compression in ctx)
○ Variable = umbilical cord compression. Repetitive if cord trapped under shoulder, around neck
○ Late = uteroplacental insufficiency, worrisome!! Can degrade into bradycardia with stronger ctx
● Bradycardia (<110 x 2min = prolonged decel; x 10min = bradycardia):
○ Face mask, roll onto (L) side, d/c pit, consider terbutaline, check cervix
○ If cord prolapsed, push it back up → to OR
○ C/S if not getting better.
Cardinal movements: engagement, flexion, descent, internal rotation, extension, external rotation (restitution),
anterior shoulder, posterior shoulder. OA is good
Stages of labor:
● Stage 1: onset of labor → complete cervical dilation (10-12h if nullip, 6-8 if multip, but big ranges)
○ Latent phase: onset → 3-4 cm, slow change
○ Active phase: 3-4cm → full dilation, fast.
■ Should have at least 1 cm / hr if nullip, 1.2cm / hr if multip (but usually 2-3 cm/hr)
● If below these guidelines, calculate MVU
■ Active phase arrest if no change in dilation or station x 2h with >200 MVU ctx
● Stage 2: complete dilation → baby time
○ Can last 1h if multip, 2h if nullip, and you get a bonus hour if you get an epidural
○ Lac repair: first degree = superficial, 2nd degree = into perineum, 3rd degree = into sphincter, 4th
degree = into rectum.
● Stage 3: baby time → placenta time
○ Retained placenta if > 30m; need to extract manually or curretage if fails (may be 2/2 accreta!)
● Stage 4 is technically the name of the immediate postpartum period (not the “recovery period”)
SVD procedures
● Operative vaginal delivery: need complete cervical dilation, head engagement vtx presentation, clinical
assessment of fetal size / maternal pelvis, known position of fetal head, adequate maternal pain control,
and ROM - then can use vacuum / forceps if 2nd stage lasting too long.
○ If baby needs to come out (e.g. FHR dropping), do operative delivery if crowning / really far down.
○ Pudendal block if no epidural in place
● Episiotomy: midline has easier repair, less pain, less blood loss but more 3rd/4th degree tears than
mediolateral (and for spontaneous delivery without episiotomy!)
○ No role for routine episiotomy / prophylactic these days.
○ May use to enlarge vaginal outlet if instruments needed, or if descent arrests
C/Section:
● Indications: breech, transverse, shoulder presentations; placenta previa / abruption, fetal intolerance of
labor, nonreassuring fetal status, cord prolapse, prolonged 2nd stage, failed operative vaginal delivery,
active herpes lesions, HIV with VL > 1000, etc. Also multiple prior C/S.
● TOLAC: need to have < 1-2 previous C/S, low transverse or low vertical incision without extension into
cervix or upper uterine segment. rupture (“pop”, decrease in IUPC pressure, FHR decels / brady, abd pain)
→ to OR immediately!
Antepartum Hemorrhage
DDx: Placenta previa, accreta/increta/percreta, placental abruption, vasa previa / fetal cord rupture
Previa: classically painless vaginal “sentinel” bleed after 28 wks (3rd trim), but nowadays mostly dx on u/s
● Placenta often will move up (repeat u/s in 3rd trimester as lower uterine segment develops)
● More common in multiple gestations, hx previa, uterine scars
● Vaginal exam contraindicated!
○ In pregnant pt with 3rd trimester vaginal bleeding, r/o with u/s before digitalizing.
● Tx: varies generally pelvic rest, esp after sentinel bleed; hospitalize if Hct drops 3pts, etc.
○ immediate C/S if unstoppable labor, fetal distress, life-threatening hemorrhage. Stabilize, ABCs,
type & cross, 2x large bore IVs, then kleihauer-Betke → RhoGAM
○ If make it to 36 wks, often will amnio for fetal lung maturity → C/S between 36-37 wks
Accreta: usually asymptomatic. Consider if previous C/s and low lying anterior placenta, for instance. Big
problem!
● Accreta = abnormal attachment into endometrium; increta = into myometrium, percreta = through to
serosa
Uterine rupture: rare. Sudden intense abd pain, vaginal bleeding, nonreassuring fetal testing, FHT disappear,
placental part regresses, IUPC → low pressure. Immediate laparotomy & delivery of fetus, then repair!
L&D Complications
Preterm labor: labor before 37 wks; preterm ctx / pain (vs cervical insufficiency).
● High risk of small baby (IUGR, SGA = small for gestational age, whereas LBW = < 2500 g)
● A/w PROM, chorio, multiple gestations, uterine anomalies, previous preterm delivery, small mom,
abruption, PEC / maternal infection, surgery, low SES
● Preterm labor and a fever- need to do amniocentesis to rule out chorio before giving steroids for lung
maturity
● Preterm contractions: don’t do tocolysis unless there’s cervical change (no labor unless the cervix is
changing). Instead, observe.
Tocolysis: Trying to buy yourself 48h for betamethasone if < 34 wks for lung maturity.
Ca-channel
Nifedipine H/A, flushing, dizziness
blockers
Betamethasone: in addition to RDS prevention, also associated with decreased intracerebral hemorrhage and
necrotizing enterocolitis in the newborn. It has not been associated with increased infection or enhanced growth.
PROM, PPROM, etc: >1h prior to labor = PROM, >18h = prolonged PROM, if < 37wks = PPROM
PROM: biggest risk is for chorio; increased > 18h; give abx ppx if expecting prolonged ROM
● Often induce if > 34-36 wks
PPROM: PROM < 37 wks EGA. gush of fluid; dx with pool / fern / nitrazine → tampon test if unsure
● Risk of chorio starts to outweigh risk of lung immaturity between 32-36 wks; management varies
● Management:
○ Antibiotics can prolong latency up to 5-7 days, so give ampicillin +/- erythromycin
○ Tocolysis - consider if < 34 wks (controversial in pprom esp without ptl)
○ Corticosteroids - consider if prior to 32 weeks usually
○ If at 36 weeks or so, just induce
Malpresentation:
● CPD and even macrosomia → can try TOL → but if failure to progress → C/S!
● Breech: frank = feet up by head, complete = feet “indian style”, footling = one foot extended.
○ Dx by U/S, Leopold’s, etc.
○ Can try ECV after 36-37 wks (spontaneous version would happen before); if fails, may retry @
39wks under epidural anesthesia
○ Trial of breech vaginal delivery - not so much in the USA. Definitely can’t try if nullip, incomplete
breech, EFW > 3,800
○ C/S is prettty much what happens.
● VTX malpresentation
○ Face: if mentum anterior, may be able to do vaginal delivery; o/w must rotate, careful with
augmentation (pressure → edema)
○ Brow: unless preterm & really small head, must convert to vtx or face to deliver
○ Shoulder: unless conversion, go for C/S (high risk cord prolapse, rupture, difficult delivery)
○ Compound:(extremity along with vtx or breech): cord prolapse risk! Can try to reduce, but careful
○ Persistent LOT / ROT or OP - may need operative vaginal delivery or manual rotation
Shoulder dystocia:
● risk increases with fetal macrosomia, cDM/gDM, previous shoulder, obesity, postterm, prolonged 2nd stage
● complications: Erb palsy / brachial plexus injury, humerus / clavicle fx, phrenic nerve palsy, hypoxic brain
injury, death.
● Dx: turtle sign after prolonged crowning of head
● Management: McRoberts / suprapubic pressure, call peds, Rubin (push shoulder across fetal chest),
Wood’s corckscrew (sweep behind post shoulder → rotate, dislodge ant shoulder), deliver posterior arm
/ shoulder.
● If that fails, then crazy stuff considered: break fetal clavicle, symphysiotomy, or Zavanelli (shove baby’s
head back inside & head for the OR!)
Maternal hypotension ddx: vasovagal, regional anesthesia, overtx with antiHTN drugs, hemorrhage, anaphylaxis,
amniotic fluid embolism (high mortality, find fetal cells in pulmonary vasculature at autopsy)
Seizures on L&D: ABCs, assess FHR, then Mag Sulfate bolus → lorazepam → phenytoin → phenobarb
Other causes of hydrops: manage all with antibody titers, amnio, MCA doppler, PUBS / transfusion
● Kelly kills, Duffy dies = cause hydrops.
● Lewis lives = cause mild hemolytic anemia. ABO causes mild hemolysis too.
Postterm pregnancy: > 42 wks. Get a nst at 40 and 41 weeks - don't just send home!
● Higher risk to mom & baby (macrosomia, oligo, meconium aspiration, intrauterine demise, dysmaturity
syndrome - look like old man!)
● #1 cause is inaccurate dating.
● Manage with more frequent visits, fetal testing (NST in wk 40, BPP & NST in 2 visits in wk 41).
○ Induce if nonreassuring testing or electively if Bishop > 6 wks 40-41; or no matter what > 42
Chronic HTN: before conception, < 20 wks EGA, or > 6 wks postpartum. Big risk for PEC.
● Treat with antiHTN (usually labetalol / nifedipine) meds.
● Get baseline ECG / 24h for Cr / protein to help with PEC dx later.
● Superimposed PEC: often dx’d with >30/15 increase (either or) in BP + 24h urine elevation. Uric acid >
6.0-6.5 also used, more controversial
Gestational HTN: blood pressure > 140/90 x 2 occasions 4-6h apart, seated.
Severe HTN (> 160 systolic or > 105 diastolic) while in hospital: treat
● goal DBP 90-100 (prevent stroke / abruption w/o compromising uterine perfusion)
● Hydralazine or labetalol are first choices
Mild Preeclampsia
● Risk factors: cHTN, renal dz, also nullip, young or old mom, hx PEC with same dad, living with dad < 1yr
● BP 140/90 x 2 and proteinuria > 300 mg / 24h (roughly 2+) and nondependent edema (face/hands)
○ Can get urine protein/Cr ratio, although not official, for spot check
● Contraindications to expectant management remote from term (<32 wks): thrombocytopenia (plt <
100,000), inability to control BP with max doses of 2 antiHTN meds, non-reassuring fetal survellance,
LFTs > 2x ULN, eclampsia, persistent CNS sx, oliguria - need to deliver now!
● Tx: Mag sulfate during L&D stay, and 12-24h after. Mag levels (mEq/L):
● 4-7: therapeutic
● 7-10: lose DTRs
● > 12: respiratory depression
● >15: cardiac arrest
● If overdose, give calcium (CaCl / Ca gluconate) for cardiac protection
Severe PEC:
● > 160 systolic or 110 diastolic x 2 occasions 6h apart; proteinuria > 5g/24h
● Can have mild PEC by BP / proteinuria but becomes severe if altered consciousness, H/A or visual
changes, epigastric / RUQ pain, impaired liver fxn (2x nL), oliguria (<400mL/24h), pulmonary
edema, thrombocytopenia (<100)
● Tx: need to deliver immediately if > 32 wks or mother crashing. If you can wait, try BMZ & check lung
maturity. “Delivery is the cure”
HELLP syndrome:
● Dx: rapidly deteriorating liver fxn (AST/ALT increases), thrombocytopenia < 100, hemolysis
(schistocytes on peripheral smear, elevated LDH, elevated total bili)
● Sx:RUQ pain (liver capsule distention), nausea, vomiting → can lead to hepatic rupture!
Acute fatty liver of pregnancy (AFLP): vs HELLP, see elevated ammonia, hypoglycemia (glc < 50), reduced
clotting factors (fibrinogen & antithrombin III) in AFLP (fulminant liver failure!)
Diabetes in pregnancy
GDM: related to hPL, diabetogenic hormone
● Not a/w congenital anomalies like pregestational DM (shows up in late 2nd / early 3rd trimester)
● But do have incr risk neonatal hypoglycemia, hypoCa, hyperbili, polycythemia; risk of maternal T2DM later
● Screen between 24-28 wks as described above. 50g 1h GLT → 100g 3h OGTT.
● White Classification: GDM A1 = diet controlled, A2 = needs meds / insulin.
○ B-->D-->C for duration. F=neFropathy, R=Retinopathy, H=Heart dz, T=prior renal Transplant
○ A2 (not A1) pts: NST or mod BPP starting between 32-36 wks; U/S for EFW between 34-37 wks.
● Treat with CHO restricted diet, exercise to enhance postprandial blood sugar control (biggest time in
gDM)
○ Tx if > 90 FBG, > 140 1h postprandial, > 120 2h postprandial.
○ Insulin (NPH x 2 doses + short-acting humalog/novolog) is conventional optino
○ Can also use gyburide / metformin (“experimental”)
● Scheduled delivery @ 39 wks if A2 commonly done; put on dextrose / insulin if needed.
○ If very poor control, may offer delivery between weeks 37-39.
○ Offer C/S to pts with EFW > 4,000g (incr risk shoulder dystocia)
Pregestational DM
● Risk factor for mom: PEC/eclampsia, SAB, infection, polyhydramnios, PP hemorrhage, C/S
● Infants of diabetic mothers
○ Including gestational DM - higher risk for hypoglycemia, respiratory distress, polycythemia,
hyperbili, hypoCa
○ Pregestational specifically: if really high HbA1c, think congenital defects (cardiac most common;
also renal / NTD / pretty much all systems. Caudal regression syndrome / sacral agenesis
classic 2/2 disproportionally high risk in poorly controlled diabetics, but not as common as others).
● Get HbA1c at outset to see status; then follow closely; good control prior to pregnancy key
○ Also should get 4mg folate daily (higher risk of NTD).
● Diet/exercise → meds / insulin as needed!
● If poor control (T2 or T1): Should get ECG (esp if HTN), HbA1c, optho consult, etc.
○ If insulin dependent, offer fetal lung maturity @ 37 wks or IOL @ 38-39wks without testing
Type 1 DM : Prepregnancy control key. Pumps are good. Don’t mess with insulin regimen until needed.
Type 2 DM: made worse by pregnancy, may go from diet/exercise or oral meds → insulin needs (manage as above)
● Fetal testing @ 32 wks, earlier if poor control. Weekly NST / modified BPP for AFI.
● Get growth U/S @ 32-36 wks
Bacterial vaginosis:
● malodorous discharge / irritation, can be asx. Gardnerella, bacteroides, micoplasma (multiple organisms)
● Dx with 3 of: thin, white, homogeneous discharge, “whiff” test with KOH, pH > 4.5, > 20% clue cells.
● increases risk for PPROM, so treat with metronidazole (clinda another option) & get TOC in 1 mo
VZV: 90% adults immune. Can’t vaccinate in pregnancy (live vaccine), but can do before / after
● Transplacental spread, a/w congenital malformations (congenital varicella syndrome) if early infection,
or postnatal infection (anywhere from benign → disseminated & death) if late in preg
● Give VZIG to mom within 96h if no hx chickenpox and exposed during pregnancy (lessens her outbreak,
but doesn’t decrease risk transmission to fetus)
● Give VZIG to infant if mom has outbreak within 5d before - 2d after delivery
● Note: maternal zoster not a/w congenital anomalies
Parvovirus B19: causes erythema infectiosum (fifth dz) - mild infection, red macular “slapped cheek” rash
● Outbreaks in elementary schools, etc. Mild in kids / adults usually
● In pregnancy: 1st tri a/w miscarriage, 2nd tri a/w fetal hydrops (attacks fetal erythrocytes → hemolytic
anemia, hydrops, death)
● If suspected exposure, check parvovirus IgM/IgG. If IgM +, think acute infection. If after 20 wks and acute
infection put baby on anemia protocol (serial U/S, MCA dopplers, PUBS / transfuse if hydrops)
CMV: subclinical / mild viral illness in mom, rarely hepatitis / mono-type picture (rarely diagnosed)
● In baby: 10% exposed develop CMV inclusion disease (hepatosplenomeg, thrombocytopenia,
jaundice, cerebral calcs, chorioretinitis, interstital pneumonitis, also MR, high mortality,
sensorineural hearing loss). No tx or PPx available.
Rubella: mom gets mild illness, maculopapular rash, arthralgias, diffuse LAD x 2-4 d
● Congenital rubella syndrome in baby, esp high transmission in 1st trimester
○ Deafness, cardiac anomalies, cataracts, MR. “blueberry muffin” baby.
● Dx with IgM titers. No tx available if acquired.
● Mom can’t get MMR in pregnancy (live vaccine)
HIV: get viral load suppressed with HAART, AZT=ZDV intrapartum and afterwards to baby to decrease trans.
● Do a C/S if VL > 1,000; otherwise can have vaginal or C/S.
● Should bottle feed
Gonorrhea:
● Screen in pregnant women @ prenatal visit, again in 3rd trim if at risk, with NAAT or cx
● Treat: IM ceftriaxone, oral cefixime. Also tx with azithromycin / amoxicillin for chlamydia too
● Causes PID only in early pregnancy. A/w preterm delivery, PPROM, other infections.
● Neonate: mucosal surfaces affected (eyes, oropharynx, external ear, anoretal mucosa). Can also be
disseminated (arthritis, meningitis)
Chlamydia: transmitted in labor. PNA is the big complication. Often asx, so screen as for GC.
● Remember, no tetracycline / doxy in pregnancy, so give azithromycin, amox, or erythromycin
HBV: from sex, blood exposure. Transplacental transmission; can lead to fulminant liver failure, etc.
● Screen everybody for HBsAg. If positive, give HBIg / HBV vax for baby after delivery.
Syphillis: T. pallidum, transmitted transplacentally; usually primary or secondary syph (need spirochetes)
● Vertical trans: intrauterine fetal demise, late abortion, or congenital syndrome (maculopapular rash,
“snuffles”, hepatosplenomeg, hemolysis, jaundice, LAD). Dx with IgM antitreponemal ab (remember,
IgM don’t cross placenta, so if baby has ‘em they’re infected)
● PCN is the only treatment - desensitize and treat with PCN if allergic!!
● Later manifestations: CN VIII deafness, saber shins, mulberry molar, saddle nose, Hutchinson’s teeth.
Toxoplasma gondii: protazoa, generally subclinical unless immunocompromised , may have vague viral illness
● Vertical trans is transplacenta, highest if third trimester acquisition. Stay away from cat feces
● Neonate: fevers, seizures, chorioretinitis, hepatosplenomegaly, jaundice, hydro / microcephaly.
● Dx with IgM in neonate, or DNA PCR via amnio to guide decision to terminate.
● Can treat mom with spiramycin (no teratogenic effects known), but doesn’t cross placenta → no effect on
baby. So use pyrimethamine / sulfadiazine along with folate to prevent bone marrow suppression if
fetal infection has been documented.
Seizure disorders: Increase in pregnancy. Watch doses (increased GFR → faster clearance).
● Phenobarb / primidone / phenytoin = folate antagonists → NTD risk. Valproic acid → NTDs too
● Take lots of folate prior to pregnancy, follow AFP, may or may not decide to switch (to single AED, lowest
possible dose) - but seizures are bad for baby too
Maternal renal disease: pregnancy can make it worse; higher risk PEC.
● Screen qtrimester with 24h urine for Cr/prot; antenatal testing from 32-34 wks onward.
● If s/p transplant, may need to increase meds to avoid rejection (higher Vd)
Maternal coagulopathies
● Pregnancy → extra coagulable. mechanism not precisely known.
● Higher risk pelvic vain thrombus 2/2 IVC compression).
● Superficial vein thrombosis: painful, visible venous cord. Rx warm compress / analgesic (won’t cause
PE) and watch for si / sx of DVT/PE
● DVT: treat with IV heparin → subQ heparin for rest of pregnancy.
○ No coumadin → nasal hypoplasia, skeletal problems
● PE: get EKG, spiral CT. Rx IV heparin → subQ heparin / LMW heparin
○ Will switch to unfractionated heparin @ 36 wks - shorter half life, so can d/c if presents to L&D
○ Can switch to Coumadin x 6mo postpartum
○ If unstable / massive, consider tPA / thrombectomy
SLE:
● Early pregnancy: high risk loss in 1st/2nd trimester 2/2 placental thrombosis, esp if antiphospholipid Ab
● Later pregnancy: also can lose 2/2 thrombosis. Antenatal testing @ 32wks onwards. Higher risk PEC
● Lupus flares: can look like PEC, but have low complement.
○ If flaring, try high dose steroids → cyclophosphamide if that doesn’t work. If PEC, deliver.
● Neonatal problems: can get irreversible congenital heart block 2/2 anti-Ro (and anti-La, but more Ro)
antibodies which cross-react with fetal cardiac conduction system.
○ Screen for anti-Ro at first visit; interventions vary.
Substance abuse:
● Alcohol: FAS possible with > 2-5 drinks / day. Growth retardation, CNS effects, abnormal facies, cardiac
defects, etc. If in withdrawal, try barbituates instead of benzos (less teratogenic)
● Caffeine: > 1 cup coffee (150 mg) may increase miscarriages
● Cigarettes: a/w SAB, preterm birth, placental abruption, LBW risk, also higher risk SIDS. Stop!
● Cocaine: a/w placental abruption, IUGR, preterm birth.
● Opiates: heroin, methadone most common. No teratogenicity. Risk is with withdrawal → put on NAS
protocol with tincture of opium, etc for baby.
Other stuff:
● Asthma in pregnancy: chronic tx: short-acting beta agonists, then inhaled corticosteroids or cromolyn,
then theophylline. acute tx: subq terbutaline, systemic corticosteroids.
● Pruritis gravidarum: mild variant of intrahepatic cholestasis of pregnancy; retain bile salt → dermis
deposits → pruritis; use antihistamines / topical emollients initially, then can try cholestyramine →
ursodeoxycholic acid if really bad.
● If appendicitis suspected, get a graded compression ultrasound (best for eval - CT has lots of radiation)
● Depression: Paxil is class D (increased risk fetal cardiac malformations & persistent pulmonary HTN)
Endomyometritis
● Polymicrobial infection, more common after C/S, higher risk if chorio / meconium / prolonged ROM
● Si/Sx: fever, high WBC, uterine tenderness, esp 5-10d after delivery but can be several weeks
● Workup: r/o retained POC with U/S. If retained POC, do blunt curettage (PP uterus can rupture!)
● Rx: broad spectrum IV abx until afebrile x 48h, no uterine pain / tenderness, normal WBC
Breastfeeding
● To suppress lactation: breast binders, ice packs, analgesics, avoid nipple stimulation (not bromocriptine
or other meds which can cause rebound engorgement and thromboembolic events!)
● Breastfeeding candidiasis: onset of pain in breast when feeding, sore / sensitive nipples. Exam: pink
shiny nipples with peripheral peeling.
● Signs that a baby is getting sufficient milk: 3-4 stools in 24 hours, 6 wet diapers in 24 hours, weight gain
and sounds of swallowing.
● Breast engorgement? Try feeding more often, taking showers, NSAIDs before feeding. Can actually lead to
fever (low grade, with breast engorged and/or hx of trouble breastfeeding)
● Prolactin causes milk production, oxytocin causes milk letdown
● Progesterone-only contraceptives are best in puerperium (don’t interfere with milk let-down) - like Depo
Gynecology
Benign Lower Genital Tract Disorders
Congenital anomalies
● Labial fusion: 2/2 exogenous androgens or CAH (21-hydroxylase deficiency) - check 17-OH progest
○ If CAH, treat with cortisol (suppresses ACTH → inhibits adrenal activity → less androgens). If salt-
wasting, give mineralocorticoids back too (fludrocortisone). Surgery to reconstruct
● Imperforate hymen: buildup of secretions (hydrocolpos / mucocolpos) in vagina, primary amenorrhea
+ cyclic pelvic pain at puberty. Surgery.
● Transverse vaginal septum: 2/2 incomplete canualization between mullerian upper vagina & urogenital
sinus-derived lower vagina. Can present like imperforate hymen, but exam shows short vagina with “blind
pouch” → U/S & MRI show upper vagina & uterus. Surgery.
● Vaginal atresia: lower vagina (from urogenital sinus) fails to develop. Primary amenorrhea, cyclic pelvic
pain too - but no introitus (“vaginal dimple”) instead; confirm dx with U/S or MRI, then surgery (e.g.
“vaginal pull-throguh”)
● Vaginal agenesis = mullerian agenesis = “mayer-rokitanksy-kuster-hauser” syndrome.
○ Congenital absence of vagina as well as hypoplasia or absence of cervix, uterus, fallopian tubes.
○ Normal external genitalia & secondary sex characteristics (normal ovaries), 46,XX.
○ Primary amenorrhea in adolescence. Dx on U/S or MRI.
○ Can create neovagina with surgery (McIndoe - buttock skin graft reconstructed) or serial dilators
(Frank/Ingram). Clearly, can’t carry pregnancy w/o uterus (but can use surrogate with her eggs)
● Vulvar vestibulitis - constellation of sx including severe pain on vestibular touch or attempted vaginal
entry, tenderness to pressure and erythema of various degrees, often sudden onset, sharp / rawness in
nature. Vulva / vestibule only. can be worsened when biking, tight shorts, tampon insertion, etc.
○ Tx - tricyclic antidepressants to block sympathetic afferent pain loops, pelvic floor
rehabilitation, biofeedback, and topical anesthetics. Surgery with vestibulectomy is
recommended for patients who do not respond to standard therapies and are unable to tolerate
intercourse.
Cysts, etc:
● Epidermal inclusion cysts on vulva: Usually go away, I&D if superinfected
● Sebacous cysts: same as above, just accumulating sebum
● Apocrine sweat gland cysts - can be occluded, abscesses → hidradenitis supperativa if multiple abscesses
form. Excise or I&D; give abx if cellulitis
● Skene’s gland cyst (near urethral meatus) -
● Bartholin’s duct cyst - “B”=”below” introitus.
○ If small (1-2 cm), watch and/or sitz bath
○ If bigger / symptomatic, can I&D & place Word catheter x 4-6 wks
○ If woman over 40, biopsy to r/o rare bartholin’s gland carcinoma
○ If recurrent, can marsupialize (suture cyst wall to vaginal mucosa to prevent reforming)
○ If abscess (infected looking), only treat if N. gonorrhea isolated, otherwise I&D sufficient.
■ If refractory or cellulitis too, can use anti-staph agents.
● Gartner’s duct cysts: remnants of mesonephric ducts (Wolffian), which normally regress in females
○ Found on anterolateral aspect of upper vagina, usually asx but can p/w dyspareunia / pain with
tampon use. Can remove surgically if needed; can bleed (may need to use vasopressin)
Ovarian cysts
● Functional - normal functioning cysts
○ Follicular = most common. From failure of follicle to rupture. 3-8cm. Asx, unilateral but can be
tender. Higher risk of torsion if greater than 4-5 cm. Resolve in 60-90d
○ Corpus luteum cyst: when corpus luteum fails to regress after 14d, or enlarges, or becomes
hemorrhagic. Can delay menses / cause unilateral lower quadrant pain. Can rupture →
hemoperitoneum. Feel more firm on exam.
● Theca lutein cysts - large, bilateral cysts, clear, straw-colored fluid. From stimulation by abnormally
high B-hCG (molar pregnancy, choriocarcinoma, ovarian induction therapy)
● Warning signs:
○ Ovarian torsion: classically waxing / waning pain & nausea. Concern if > 4cm
○ If premenarchal or postmenopausal, think neoplasm & do ex-lap
○ If persist > 60 days, are solid or complex on U/S, or larger than 8 cm in reproductive woman,
think neoplasm → diagnostic laparoscopy or laparotomy.
● Follow up with pelvic ultrasounds serially to check for cyst resolution;
○ CA-125 if concerned for cancer
○ Start patients on oral contraceptives during observation period (to prevent future cysts)
○ Cystectomy / evaluation via laparoscopy / laparotomy if no resolution in 60-90d
Endometriosis / Adenomyosis
Endometriosis: Endometrial glands / stroma outside of endometrial cavity
● endometrioma = cystic collection in ovary (“chocolate cyst”)
● Severity of sx doesn’t correlate with amount of endometriosis
● Dx: really need surgical confirmation by direct visualization
● Sx: cyclic pelvic pain starting 1-2 wks before menses, peaking 1-2d prior to menses, then subsiding
○ Also dysmenorhea, dyspareunia, abnl bleeding, infertility
● Tx:
○ expectant management if minimal sx or trying to conceive
○ medical: suppress / atrophy endometrial tissue
■ OCPs / progestins to create “pseudopregnancy” (suppress menstruation)
■ Danzol (androgen derivative; can cause acne/hirsutism/virilization) or Lupron (GnRH
agonist; causes menopausal sx) to create “pseudomenopause” (suppress FSH / LH; ovaries
don’t create estrogen → less sx).
● Can use “add back” therapy with small amt estrogen along with Lupron to minimize
sx of menopause, lessen bone loss.
○ surgical: laparoscopy + fulgaration for implants, laparoscopic cystectomy for endometriomas
■ Definitive = TAH/BSO, lysis of adhesions, fulgaration
Vulvitis: usually candidasis. If chronic, always rule out malignancy. Could also be 2/2 irritants, etc.
Ulcers:
● Syphillis (T. pallidum).
○ Primary = chancre on exposed mucosa, painless / red / round / firm / well circumscribed.
Develops 3wks after exposure; some LAD too.
○ Secondary = disseminated. maculopapular rash including palms / soles 1-3mo after exposure
○ Latent: early if < 1yr, late if > 1 yr
○ Tertiary = uncommon, years later. granulomas / gummas of skin, cardiovascular syphilis
(aortitis), neurosyphilis (tabes dorsalis, general paresis).
○ Dx:
■ dark field microscopy from chancre / granuloma is gold standard
■ RPR/STS → FTA-ABS for serology / screening.
○ Tx: PCN G 2.4M units x 1; if late latent, do it weekly x 3 wks.
■ Alternatives: tetracycline PO 4x/day x 2wks, doxy 100mg PO BID x 2wks, or ceftriaxone
1gm IM/IV daily x 8-10d, but desensitize & give PCN, especially in pregnancy!
■ If neurosyphilis, need IV PCN G q4h x 10-13d.
■ Follow RPR / VRDL titers - should see decrease @ 6mo, nonreactive @ 12-24mo
○ Jarisch-herxheimer rxn: from death of spirochetes; after starting PCN, fever, chills, H/A, myalgia,
malaise, pharyngitis, rash w/in 24h. Shouldn’t prevent / delay therapy
● HSV:
○ grouped vesicles / ulcers with burning, pruritis.
○ Dx: DNA PCR, or Tzanck smear classically.
○ Rx:
■ Primary infection: acyclovir, famciclovir, valacyclovir
■ If severe or immunocompromised, IV acyclovir
■ If recurrent, oral acyclovir x 5d
■ Chronic infection: valacyclovir can lessen transmission, reduce outbreaks
■ If pregnant, C/S
● Chancroid (H. ducreyi).
○ Painful, well-demarcated, non-indurated ulcer with painful supperative inguinal LAD
○ Very rare in USA.
○ Dx with culture (chocolate agar), hard to do.
○ Tx with ceftriaxone IM x1, azithro PO x 1, or longer cipro / erythro regimens. treat partners too
● LGV (C. trach L1-3)
○ First stage: painless, transient local lesion (papule / ulcer) → Secondary stage: inguinal
syndrome (painful enlargment / inflammation of inguinal nodes, fever / H/A / malaise, anorexia)
→ Tertiary stage: anogenital syndrome (proctocolitis, rectal stricture, rectovaginal stricture,
elephantiasis.
○ Dx: clinical suspicion, can also use cx / immunofluorescence / NAAT
○ Rx: doxycycline 100 mg PO BID or erithroymycin x 21 days.
Non-ulcerated lesions
● Condyloma acuminata (genital warts) - caused by HPV
○ Raised papillomatous wart → can grow to large pedunculated lesions. Bx if uncertain
○ Prevent with gardasil.
■ Treat with local excision, cryo, topical TCA or 5FU
■ Can also use imiquimod or podofilox self-treatment if motivated
● Molluscum contagiosum (pox virus)
○ Small umbilicated “water warts”, anywhere except hands / feet. Clinical dx.
○ Rx: local excision or TCA / cryotherapy
Vaginal infections
● Bacterial vaginosis: shift from lactobacillis → other microorganisms, incl Gardnerella
○ Dx: 3 of [whiff test, thin white homogenous discharge, > 20% clue cells, nitrazine pH > 4.5]
○ Tx: metranidazole 500mg PO BID x 7d or clinda. PO > topical for efficacy. No EtOH with metro
● Candidaisis
○ A/w diabetes, recent abx, immunocompromise, intercourse, etc.
○ Sx: Pruritis, burning, dysuria, dyspareunia, discharge
○ On exam: satellite lesions, cottage cheese-like discharge
○ Dx: KOH prep showing branching hyphae & spores
○ Tx: azoles
■ Topical / suppository = miconazole, terconazole; Nystatin too
■ PO: fluconazole = Diflucan 150 mg PO x 1
■ If recurrent, consider non-albicans species (can be resistant to azoles); try longer duration
and may need weekly PO fluconazole x 6mo
● Trichomonas vaginalis: STD, unicellular anaerobic flagellated protozoa
○ Sx: profuse discharge (yellow / gray / green / frothy) with unpleasant odor, pruritis, worse just
after menses 2/2 vaginal pH increase
○ Exam: pH in 6-7 range, vulvar erythema / edema / pruritis, “strawberry cervix” (but only 10%)
○ Dx: wet prep → trichomonads; NAAT is more sensitive, cx rarely done but most sensitive / specific
○ Tx: metronidazole 2g PO x1 and treat partner as wel
■ Vs BV tx, which is for 7d and no partner treatment needed
PID
● Higher risk infertility, ectopics afterwards.
● Sx: abdominal / adnexal pain; can be unilat / bilat, may be absent, also vaginal discharge / bleeding / UTI
sx. Fever is actually less common (20%).
○ Fitz - Hugh - Curtis syndrome = perihepatitis; RUQ pain and LFT elevations too
● Dx: Pelvic pain + one or more of [cervical motion, uterine, or adnexal tenderness]
○ Fever, elevated WBC, mucopurulent cervical discharge, elevated ESR/CRP are supportive
○ Get cervical cultures for etiology, but usually polymicrobial (cx results don’t affect tx)
■ GC/CT are most common, but also anaerobes, E. coli, H. flu, gardnerella, strep
○ Definitive dx with laparoscopy / pelvic imaging with PID findigns / endometrial bx
● Tx: hospitalize (esp if teenagers, nullips, noncompliant), get fluid status under control
○ IV abx: broad spectrum cephalosporin (e.g. cefoxitin) and doxycycline (for atypicals)
○ After 24h afebrile, can d/c IV abx but continue doxy. If allergic, can use clinda + gent
○ For o/p tx, ceftriaxone IM x1 + PO doxy +/- metronidazole x 14d
Toxic shock syndrome: now uncommon, was often 2/2 long term tampon use; 2/2 S. aureus producing TSST-1
● high fever, hypotension, diffuse erythematous macular rash, desquamation of palms / soles 1-2wks
later, GI disturbances, renal failure, plts < 100k, alteration in consciousness, etc.
● Blood cx often negative (toxin absorbed via vaginal mucosa)
● Tx: always hospitalize; fix hypotension / fluid status first.
○ Abx decrease risk of recurrence only (clinda + vanc) but since it’s toxin-mediated, doesn’t shorten
current infection’s course.
HIV: ELISA for screening → Western for confirmation; then get VL / CD4. Get ‘em on HAART.
● Increased risk cervical cancer - so do Pap smears initially and at 6mo, then yearly if negative.
Anywhere Vaginal vault prolapse Sacrospinous ligament suspension: suture endopelvic fascia of
vaginal apex to sacrospinous ligament (vaginal approach)
(collapsing after
Abdominal sacral colpopexy: use mesh, attach vaginal apex to sacrum
hysterectomy)
(abdominal approach)
Urinary Incontinence
Nerves: CNS inhibits; parasympathetic → pelvic nerve from S2-S4 helps urinate, as does somatic → pudendal nerve.
Workup:
● Voiding diary (when are you leaking?)
● Do U/A and UCx to r/o infection
● Can get urodynamics, PVR, etc.
● Standing stress test: stand over towel & cough.
Type Dx Etiology Notes / Tx
Mixed symptoms of Both stress & detrusor imipramine (TCA) especially good if mixed incontinence
Mixed
above activitity (both anticholinergic & alpha-adrenergic)
Meds:
● Reduce urethral closing pressure (prazosin,
Poor / absent bladder
Frequent / constant terazosin, phenoxybenzamine)
contractions (or more
Overflow dribbling, also stress / ● Striated muscle relaxants (diazepam, dantrolene)
rarely obstruction) →
urge incontinence. ● Cholinergic agents (bethanecol) to increase
retention → overflow
contractility
Intermittent self-cathing used too.
Dx with indigo
carmine instilled into Urinary fistula after
Fix fistula (surgery)
Bypass bladder, then tampon. pelvic surgery or
Use abx for UTI / estrogen if postmenopausal / etc
Can use IVP / radiation, esp TAH
cystogram / etc too
Nursing home,
Functional geriatrics, poor Can’t get to bathroom Fix social situation, psych consult, SW, etc.
mobility
Stress incontinence: Use sling if hypermobile & intrinsic sphincteric deficiency combined
● Use retropubic urethropexy if stress incontinence for hypermobility alone (sling can be obstructive as
well - higher rate of retention, voiding dysfunction).
● Use urethral bulking if stress incontinence for intrinsic sphincteric deficincy alone
Puberty
● Adrenarche (zona reticularis in adrenal starts making androgens), then gonadarche (pulsatile GnRH)
○ Adrenarche: ages 6-8; Gonadarche around age 8
● Thelarche (~10 y/o)→ pubarche (~11)→ growth spurt peak velocity (9-10)→ menarche (12-13, or
usually ~2.5yrs after thelarche). Earlier in AA, later in Caucasians / thin girls / etc.
● True precocious puberty (due to pulsatile GnRH secretion) - treat with nonpulsatile GnRH
Menopause
Definition: 12 months of amenorrhea after last menstrual period. Avg age 51, but big range.
● Perimenopause before that point - can still have periods! Get OCPs, not HRT
● Sx: Hot flashes, mood changes, insomnia, dyspareunia. Sx usually disappear w/in 12 mo
● Signs: vaginal / cervical atrophy
● Decreased estrogen, FSH elevation / LH too, but just supportive (not diagnostic)
● Also increased coronary artery disease risk, accelerated bone resorption → osteoporosis
Osteoporosis:
● Osteoporotic fx hx - can treat with bisphosphonates right away without waiting for dexa results
● Osteoporosis risk: consider getting DEXA (everybody @ 65 y/o, or @ 60 y/o if high risk)
● Treatment
○ Bisphosphonates (if pathologic fx of hip or vertebrae, other fx and T-score -1.0 to -2.5, or T
score < -2.5).
○ Should be taking 1000-1500 mg Ca daily no matter what; if osteoporotic, 800 IU vitD too.
○ SERMs help with osteoporosis too.
Secondary amenorrhea
● Pregnancy is #1 cause!
● Anatomic abnormalities:
○ Asherman syndrome (intrauterine synechiae in pt s/p myomectomy, C/S, D&C, endometritis)
○ Cervical stenosis 2/2 surgical, obsetric trauma
● Premature ovarian failure - often idiopathic, also 2/2 torsion, surgery, infection, radiation, chemo
○ Symptoms of menopause before age 40; do chromosomes if < 35 y/o
● PCOS = Stein-Leventhal syndrome
○ chronic anovulation, oligomenorrhea / amenorrhea, hirsutism, obesity, enlarged polycystic ovaries
○ Increased LH:FSH ratio → kills follicle, more androgens → hirsutism
○ Treat with OCPs / cyclic progestins / Depo to suppress endometrial hyperplasia / etc
■ Treat with Clomid if fertility desired, however.
○ Screen these pts for for T2DM
● Hyperprolactinemia: amenorrhea, galactorrhea
○ Prolactinoma is #1 cause; rx with cabergoline / bromocriptine (dopamine agonists) if
asymptomatic / microadenoma, or surgery if big & causing problems
○ Hypothyroidism → increased TSH → increases PRL secretion as well
○ Meds: dopamine agonists (Haldol, Reglan, other antipsychotics), TCAs, MAOis
○ Everybody should get imaging to r/o prolactinoma.
● H-P-A axis disruption: stress, anorexia, etc.
Dysfunctional uterine bleeding (DUB): diagnosis of exclusion (abnormal bleeding & no other etiology)
● Usually 2/2 anovulation → no corpus luteum → no progesterone → no withdrawal; endometrium just
grows until blood supply can’t keep up, then breakds down.
● W/u for hypothyroidism, hyperPRL, hyperandrogenism, PMOF
● ANY WOMAN OVER 35 WITH ABNORMAL UTERINE BLEEDING GETS AN ENDOMETRIAL BX
○ Also true for obese women < 35 with extended oligomenorrhea
● Tx:
○ If acutely hemorrhaging, give IV estrogen for quick relief (but risk DVT/PE) or oral estrogens if
hemodynamically stable (lower risk, but takes 24-48h)
○ For chronic DUB, use NSAIDs to decrease blood loss, regulate periods with OCPs or progestin only
if estrogen contraindicated
○ If refractory, consider surgery (D&C is first step → endometrial ablation if done with kids).
Hysterectomy is definitive treatment; can leave ovaries too.
Postmenopausal bleeding: always abnormal! Atrophy is #1 cause, but rule out cancer. HRT can cause too.
● Also check for non-GYN causes (hemorrhoids, anal fissures, rectal prolapse, lower GI tumors, urethral
caruncles)
● W/U: CBC, TSH, PRL, FSH; Pap smear, DRE, tumor markers if adnexal mass identified, endometrial
biopsy. Image with pelvic U/S, sonohysterogram, MRI to get endometrial stripe thickness.
Hysteroscopy for polyps / fibroids, and D&C also useful.
Sources of androgens: can be adrenal (DHEAS elevated) or ovarian; both result in increased free T levels.
Adrenal disorders:
● Cushing syndrome: Cushing disease if from ACTH-secreting pituitary adenoma; also can be paraneoplastic
or 2/2 adrenal tumor (which would suppress ACTH). Get overnight dexamethasone suppression test
(should decrease endogenous production if normal negative feedback); or 24h urine for cortisol
● Congenital adrenal hyperplasia - usually 21alpha-hydroxylase deficiency, causing 17-
hydroxyprogesterone to build up (gets shunted down androgen pathway). Also don’t make cortisol or
mineralocorticoids (adrenal insufficiency - hypotension, etc, and salt wasting); if female, can present with
ambiguous genitalia at birth or have late onset virilization.
○ Can also be 11-beta hydroxylase (precursor builds up with mineralocorticoid activity, so
hypertensive) or 3B-HSD deficiency too.
○ Always check 17-OHP level; can confirm with ACTH stim → check 17OHP 1h later (big rise =
CAH). Lower elevations can be c/w late-onset CAH or heterozygotes
● Can suppress adrenal production with prednisone 5mg qhs
Ovarian disorders: nonneoplastic
● PCOS (see above)
● Theca lutein cysts: LH → theca cells → androgens → granulosa cells → estrogens normally
○ These cysts make too many androgens! A/w molar pregnancy. Dx with Bx
● Stromal hyperplasia / hyperthecosis: pts age 50-70, uniformly enlarged ovaries, large & fleshy
○ Areas of high utilization inside hyperplastic stroma
● Can generally treat these with OCPs, which suppress LH/FSH and increase SHBG
○ GnRH agonists + add-back estrogen are another option
Drugs: steroids, minoxidil, phenytoin, diazoxinde, cyclosporin can all cause virilization
Idiopathic hirsutism: can try finasteride (inhibits 5-alpha reductase) or sprionolactone (antiandrogen)
● These in addition to OCPs; Lupron / Depo-provera are also reasonable 2nd line if not on OCPs
Other stuff
● Hair loss postpartum - high estrogen levels in pregnancy cause increased synchronicity of hair growth, so
that there can be significant alopecia afterwards (all hair in same phase, falls out at same time) - nothing to
worry about.
Contraception / Sterilization
Stuff that kind of works
● Periodic abstinence (ha!) with ovulation kits, calendars; coitus interruptus, lactational amenorrhea
(but will start to ovulate before return of menstration usually in 6-12 mo)
● Emergency contraception - Plan B (progestin only) within 72h. Need Rx if < 18, OTC if > 18.
○ Plan B, the levonorgestrel pills can be taken in one or two doses and cause few side effects. Oral
contraceptives need to be taken 12 hours apart if using those.
■ Indicated sooner than 72h if possible and no later than 120h
■ Can insert second dose of ocps per vagina or take an antiemetic 1 hr before administration
to decrease nausea/vomiting (major side effect
○ Copper IUD can be put in within 5-8 days, actually the most effective form of emergency
contraception
Sterilization
● Tubal ligation
○ Can be done laparoscopically (clips, cautery, banding)or hysteroscopically (Essure, Adiana);
○ Can do immediately postpartum through small subumbilical incision
○ Essure - takes 12 weeks, use backup birth control until HSG confirms complete occlusion
○ Leads to a slightly decreased risk of ovarian cancer (mechanism unknown)
○ Age < 30 have highest regret for procedure
● Vasectomy:
○ Not immediately effective! Use alternate contraception until repeat semen analysis in 6-8wks
○ Simpler, safer, more effective than BTL
○ Can form antisperm antibodies, but no long-term effects.
Other stuff:
● If tissue needed for karyotype, etc should do medical abortion (mifepristone / misoprostol prior to 49
days, or induction with prostaglandins if 8 0/7 or later).
● Make sure to give RhoGAM if Rh negative (at time of termination) - both medical & surgical!
● Give abx (doxy, ofloxacin, or ceftriaxone) to prevent postabortion endometritis
● Rough guide: termination is legal if < 24 wks (threshold of viability) or later if abnormality incompatible
with life
Treatment options
● Clomiphine citrate: SERM, estrogen antagonist at hypothalamus, stimulates GnRH production → increased
LH/FSH surges → ramps up follicular development
● Letrozole: aromatase inhibitor, decreases peripheral estrogen production → more GnRH → more LH/FSH
→ more follicles, etc. Decreases peripheral estrogen (good for fertility in breast cancer pts, etc)
● Metformin: insulin sensitizer (biguanide), but some studies suggest it doesn’t help in PCOS
● Human menopausal gonadotropins: purified FSH/LH, next line after Clomid
● Follistatins (Follistim) - recombinant FSH, stimulates follicular development
● Recombinant hCG - similar to LH, used to trigger ovulation after follicle stimulation
● Pulsatile GnRH - can be used to increase FSH/LH release. Often used for HPA axis failure (e.g. low wt)
● Can try surgery too - for endometriosis, or tuboplasty with reanastamosis (although many go straight to
IVF), or uterine factors (cut synechiae, remove polyps, etc)
Problem Try
Complications:
● Multiple gestations
● Ovarian hyperstimulation syndrome (OHSS) - ovarian enlargement, can lead to torsion / rupture, can be
complicated by ascites / pleural effusion / hemoconcentration / hypercoagulability / renal failure / even
death
Preimplantation genetic diagnosis: evaluate embryo for genetic abnormalities before implanting into uterus
● e.g. for pt with hx of Huntington’s, sickle cell, etc
Preimplantation genetic screening: screen for conditions, usually chromosomal, screening for aneuploidy
● e.g. for advanced maternal age, etc.
Vulvar / Vaginal Neoplasia
Preinvasive Vulvar Disease: either squamous (VIN) or nonsquamous (Paget / melanoma in situ)
● VIN: cellular atypia within epithelium. VIN I/II/III based on depth of involvement.
○ Risks: HPV 16/18 associated (if younger pt, HPV associated, faster / more aggressive; if older
often not HPV-associated and slower moving), also smoking / immunocompromise.
○ Dx: many asx & picked up on exam, also pruritis / irritation / dysuria. PE: flat or raised, red or
white or pigmented, can be multifocal. Need colpo to look for additional lesions
○ Management: get bx to look for invasion; if no invasion, wide local excision with split-thickness
skin graft afterwards. Can also do laser vaporization - but bx first, since no tissue left behind.
■ If younger, can try 5-FU / imiquimod to preserve anatomy, but can’t be invasive and need
to follow up closely (lower effectiveness)
■ If older, may chose vulvar vulvectomy
■ Close follow up (1/3 will recur) - colpo q6mo x 2y then annually
● Paget disease of vulva: rare, intrapithelial neoplasia a/w coexistent adenocarcinoma
○ Dx: chronic inflammatory changes (hyperemia, well demarcated thickening / excoritation), often
velvety red lesions → white plaques after chronic itching 2/2 pruritis. Most common in pts > age
60 with vulvar pruritis / vulvodynia
○ a/w breast cancer (although not as much as paget disease of breast),
○ May be confused with lichen sclerosis, although paget disease has more hyperkeratotic
appearance and doesn't respond to steroids.
○ Tx: wide local excision but high recurrance rate; fatal if spreads to LNs
● Melanoma should be on DDx as well; often p/w invasion.
Vulvar cancer
● Most commonly squamous cell carcinoma, also melanoma / BCC / soft tissue sarcomas
● Most lesions unifocal on labia majora, can have varied appearance. Mostly older women (65 is avg age).
● Spreads via lymphatics & direct extension
● Risk factors: menopause, smoking, VIN/CIN, HPV, immunocompromise, hx cervical cancer
● Tx if bx proven - need radical vulvectomy and bilateral inguinal lymph node dissection.
○ If microinvasive (bx of small (<2 cm), well-differentiated lesion, with invasion <1.0 mm), then
and only then can you consider wide local excision.
○ If metastatic, use pelvic radiation as adjunct.
● If melanoma, don’t do lymphadenectomy (if metastasized, high mortality).
Vaginal Cancer
● VAIN is premalignant form; classified I-II-IIII (III = > ⅔ epithelium thickness)
○ A/w CIN, cervical cancer, condylomas, HPV, etc. (majority have neoplasia / Ca of vulva/cervix)
○ Dx: Almost always asymptomatic but can have some spotting or discharge; picked up on Pap
■ Consider if persistent abnormal Pap but no neoplasia on cervical bx
■ Bx the lesions!
○ Tx: local excision.
■ If invasion ruled out, can try laser vaporization or 5-FU (esp if multiple lesions or
immunocompromised)
■ Get close follow up with colpo
● Vaginal cancer: mostly SCC; adenoCa / sarcoma / melanoma less common.
○ Consider clear cell adenocarcinoma if hx of in utero DES exposure
○ Usually posterior wall, upper ⅓ vagina; spreads via lymphatics or hematogenous
○ Mostly older women > 60
○ Dx: postmenopausal bleeding / postcoital spotting / watery or bloody discharge.
■ Often may be diagnosed on Pap
○ W/U and staging: CXR, cystoscopy, sigmoidoscopy, IVP for local invasion
○ Tx:
■ Small in upper ⅓ vagina → surgical resection
■ Large (>2cm) or in lower ⅔ vagina or stage III/IV → radiation therapy alone
■ If adenocarcinoma, treat similarly.
Colpo results
● Worrisome: acetowhite changes, mosaicism, punctations, atypical vessels → biopsy these!
● Path results:
○ CIN I = repeat cytology q6mo x 2 or repeat HPV testing in 1 year
○ CIN II / III: treat with surgical excision (LEEP > cold knife cone)
● After colpo, need to do a cone / Leep excision if adenoCa in situ, positive endocervical curretage (LSIL,
HSIL, etc), unsatisfactory colpo (can’t visualize entire transition zone, etc), or big discrepancy between
Pap & bx results (e.g. HSIL on Pap, then normal colpo → need excision!)
● LEEP complications: cervical stenosis, insufficiency, infection, bleeding.
CIN
● Disordered growth & development, starting at basal layer.
● Most commonly during menarche and after pregnancy (more metaplasia) → metaplasia of transition
zone
● HPV 16/18/31/45 are high risk types - get ‘em Gardasil
○ Other risk factors: cig smoking, immunodeficiency (HIV)
Cervical cancer: 80% SCC, most of rest is adenoCa (think clear cell adenoCa with DES exposure in utero)
● High risk serotypes, immunosuppression, etc (cervical cancer = HIV-defining illness)
● Dx: usually asx (need to screen with Paps!). Can have postcoital bleeding, see mass on spec exam, etc
○ Cancer can only be diagnosed with tissue bx, not with Pap!
● Staging is clinical (only GYN cancer with clinical staging) - look for invasion to adjacent structures /
metastasis (EUA, CXR, cystoscopy, proctoscopy, IVP, barium enema).
○ MRI / CT can’t be used for staging; also, staging doesn’t change based on operative findings
○ Stage I: confined to cervix
○ Stage II: beyond cervix but not to lower ⅓ vagina or pelvic sidewalls
○ Stage III: to pelvic sidewalls or lower ⅓ of vagina
○ Stage IV: beyond pelvis, or into bladder/rectum, or distant mets
● Treatment:
○ If preinvasive / microinvasive (stage I-Ia) → simple hysterectomy
■ consider cold knife cone if fertility highly desired
○ If early (stage Ia-2 to IIa) → radiation or radical hysterectomy + bilat LN dxn
■ Includes parametria, upper vaginal cuff, uterosacral / cardinal ligaments, vascular supply
■ Decision based on age, ability to tolerate surgery, ?nearby rad facilities
■ If young, may lean towards surgery (keep ovaries!0
○ If advanced (IIb-IV), treat with chemoradiation (cisplatin-based + internal & external rad)
○ If recurrent, can treat with pelvic exenteration & get 50% survival
○ Palliation: cisplatin chemo and/or palliative radiation
Endometrial Cancer
#1 common / curable GYN cancer in USA
● Risk factors: unopposed estrogen (obesity, chronic anovulation, nullip, late menopause, exogenous
unopposed estrogen, early menarche, tamoxifen use), also HTN / DM, HNPCC, breast Ca hx, BRCA 1
● Protective: OCPs, combination HRT, high parity, pregnancy, physical activity, smoking (weird.
● Subtypes
○ Younger women: type I, estrogen-dependent, more favorable prognosis.
○ Older thin white women: type II, non-estrogen dependent, less favorable
● Most are endometriod adenocarcinoma, with complex atypical hyperplasia as precursor
● Extension is direct to cervix / outward through myometrium → lymphatics eventually; heme less common
● Grade is most important prognostic factor
● Sx: postmenopausal / abnormal vaginal bleeding. can also see pelvic pain / mass / wt loss if advanced
● Dx: endometrial biopsy → D&C (if suspicious findings on EMB)
○ Also get TSH, PRL, FSH as part of w/u; may also get CA-125 (if super high, maybe advanced), Pap
○ Pelvic U/S (postmenopausal should have endometrial stripe < 4-5mm).
■ Even if normal endometrial stripe & pelvic U/S, need to get tissue (EMB/D&C)
● Staging:
○ Stage I: Ia limited to myometrium, Ib/c into myometrium
○ Stage II: cervical invasion
○ Stage III: into serosa / peritoneum / vagina / pelvic or periaortic LN
○ Stage IV: invades bowel / bladder, or distant mets
● Treatment:
○ Stage I / II: TAH-BSO (get rid of ovaries → less estrogen); may also need LN dxn and/or rads
○ Stage III / IV: TAH-BSO + radiation + pelvic / periaortic LN sampling
○ Advanced/recurrent: high dose progestins; ?chemo
○ Good 5 year survival!
Ovarian Tumors
Worry about pelvic mass if >8cm, solid or cystic+solid, nodular, multilocular, + doppler flow, bilateral
Epithelial tumors (65-70%) Germ cell tumors (15-20%) Sex cord stromal (5-10%)
Germ Cell
● Most grow rapidly, limited to one ovary, stage I at time of diagnosis, curable! 95% benign
● Sx: capsule distention → pain, hemorrhage, necrosis → acute pelvic pain; can also torse / rupture
Type Differentiation Notes Marker
Differentiation:
Choriocarcinoma hCG
Trophoblastic (placental)
● Treatment:
○ for benign tumors (mature teratomas) → cystectomy or oophorectomy
○ for malignant tumors, unilateral salpingo-oophorectomy if fertility desired, or TAH/BSO
○ everything except stage IA dysgerminomas / immature teratomas gets multiagent chemo
■ Usually BEP = bleomycin, etoposide, cisplatin=Platinol
■ Can follow response with tumor markers
○ Dysgerminomas are uniquely radiosensitive - but often still do combo chemo to protect fertility
Malignant GTD
● Types
○ Persistent / invasive moles (75%)
■ Arise after evacuation of molar pregnancy: hydropic villi / tropoblasts invade myomet.
■ Rarely metastasize; can regress spontaneously
■ Dx: plateauing / rising hCG after tx for molar pregnancy, can have uterine bleeding
■ Tx: single agent chemo (MTX / actinomycin D) if low risk, multiagent if high risk
○ Choriocarcinoma (25%)
■ Pure epithelial tumor; sheets of anaplastic cytotrophoblasts without villi.
■ Tissue diagnosis is the standard in establishing a diagnosis of most all malignancies, with
the exception of choriocarcinoma. Only a positive beta-HCG in a reproductive-aged
woman who has a history of a recent pregnancy (term, miscarriage, termination, mole)
is necessary to establish the diagnosis
■ Malignant, necrotizing, arises weeks/years after pregnancy
■ Often metastatic, can spread hematogenously (lungs / vagina / pelvis / brain / liver / GI)
■ Present with late postpartum bleeding or irregular bleeding years later
● Mets to lungs → cough, resp distress, hemoptysis
■ Get hCG, CBC/coags, pelvic U/S (doppler → really vascular), CXR/chest CT for lungs,
abd/pelvic CT or MRI to look for mets as well.
■ Tx: single agent chemo / multiagent chemo depending on prognosis
Mammograms:
● Should have yearly mammogram starting at age 40; continue as long as the woman is in good health
○ No upper age limit!
● If strong FHx breast cancer (mother or sister), mammogram screening 5 yrs earlier than youngest
family member’s diagnosis or 10 years if family member was premenopausal.
Breast masses
● Never dismiss a mass just because mammogram is negative
○ Think malignant if firm, nontender, poorly circumscribed, immobile
● W/U: get U/S for women < 30, mammogram for women > 30
○ If concerning on imaging or exam, get tissue
■ Cystic → aspirate ; excise cyst if bloody fluid or persistent
■ Solid →
● fine needle aspiration if < 30 → excisional bx if FNA fails, or nondiagnostic
● core needle biopsy if > 30
■ Nonpalpable → excisional bx under needle / wire guidance
Noninvasive disease:
● Lobular carcinoma in situ (LCIS) - neoplastic epithelial cells in breast lobules without invasion of stroma
○ multicentric & bilateral; often picked up incidentally on bx for another finding (can’t see on
mammograms and can’t palpate on PE)
○ premalignant lesion - 25-30% risk of invasive breast cancer w/in 15 yrs in either/both breasts
○ Tx: Observe only; may consider SERM to decrease risk - otherwise close followup
● Ductal carcinoma in situ (DCIS) - malignant epithelial cells in mammary ducts, not stroma
○ Higher capacity to progress to outright invasive ductal cancer in same site
○ Mammogram → clustered microcalcs +/- palpable mass
○ Dx: needal localization bx or excisional bx if palpable
○ Tx: surgical excision of all microcalcifications with wide margins
■ May need simple mastectomy if extensive only
Invasive disease:
● Types
○ Infiltrating ductal carcinoma (70%) - from ductal epithelium, usually unilateral
○ Invasive lobular carcionoma (10-20%) - from lobular epithelium, often bilateral
○ Paget disease of nipple (1-3%) - often with DCIS / invasive carcinoma in subareolar area
■ Malignant cells invade nipple epidermis → eczematous changes w/ scaling, erosion, etc.
○ Inflammatory breast carcinoma (1-4%) - really aggressive, poorly differentiated
■ Dermal lymphatic invasion → peau d’orange
● Treatment:
○ Modified radical mastectomy or [lumpectomy + radiation] but need to be able to get rads
■ Get sentinel LN biopsy
■ Breast reconstruction afterwards
○ Hormone status: ER/PR+ = better prog, HER2/neu = worse prognosis
■ If ER+, usually use tamoxifen x 5 yrs; letrozole / anstrozole (aromatase inhibitors) even
better if postmenopausal (most estrogen coming from fat!)
● Remember tamoxifen predisposes to endometrial cancer!
■ If HER2/neu+, may try trastuzumab (mAb vs HER2/neu)
○ Metastatic / recurrent
■ ER-: combo chemo
■ ER+:
● consider oophorectomy / GnRH antagonists if premenopausal,
● consider tamoxifen / aromatase inhibitors if postmenopausal
○ Systemic adjuvant chemo along with hormonal therapy if indicated often used
● Prognosis: stage is #1 predictor, also ER/PR status and lymph node status
● F/U:
○ PE q3-6mo x 3y, then space to q6mo x 2y, then q12mo
○ Mammogram @ 6mo, then annually
○ Avoid HRT