aT pap labe ttt of OB-G¥N mudt-knows Td brain aya Ces ea aa Williams Obstetrics 24th Fd. & eee eee Lc} oath g erate on ne evra) Tran Pahoa ne mora Ue ere— Table of Contents — Ww. Riskofrupeure ¥)——_Indications to Vaginal Birth after CS. «vBac) c 17. Menstrual Gycle = p47 Friedman's Curve i fb torso Manion B, Contuerof Normal aber om A coecangunaiaed “ae of Labor ). Abnormal Uterine Bleeding ~ & #8 Pi Sage oa . Definition | : i ‘ Bile * : 1 Diagnosis of Pregnancy ~ 3 fattest een | : tamptve Symon of Pregnarc erperiu bneciorenear ee Wh rohail ree ot Prepay 9.1 re ies | " Sasa tmer intrapart seme One nan eee beh gai haere gs : fi, Abnormal t aternal adaptations of Pregnancy ~ Fea Near Pawerns 2 10. virseTelirisies Hemorrhagic 4 Respirory stem, Diseases - p. 25 wv ecraeae © ty Ccbtlaal Trophcbtese Disease S, Eesgieciem {i Gevuatonal Trophobiase Turow — 11. Third Trimester Bleeding - p32 Geencan i Placenta previa t PacationfDuron of Premancy . ee cei acneme 12, Placenal Disorders— 9.84 | faces Ralo 1 SS Abnormalities of placenta fel fe abby Beaminaons a scam ¥._Prequenc) of vss : — Yenc ay aban iii, Abnormalities of Amniotic Fluid a aa 18. Complications of Pregnancy = p. 35 5: Mii, TenDarger Sign of Pregnancy i. Mel tthe Passages - 9. 9 th Mulecfeal Pregnancy ‘The Passages - p eo Pree taber to eaeee, 3. Poscuerm Pregnancy a % OT I Rlneaf Cron Dae vil Lctrauterine Growih Restriction | = 14. Dywocta- at | 4 - 1 aetmales f h owes | 5 t—_Rormalte of ge The Pawenger =p. 12 1. Complications of Dystona ¥ 4 senne 45, Instrumental Vaginal Delivery - p. 44 Ti Fetal Presentation : ee FeatFowon recs ies | 6. Assessment of Fetal Well-being - p. 13 16. ae eee Chinical Assessment of Feral Well-being + Caesarean Section = Att LSet eal We actos og yycal Aesarn i, Coneraindications to fi, —_Ulasound in Pregnancy ti, Teehmques oS ! of Parturition = 1 2 - ‘of parturition kari ct fii. Eflacement iw.20. amenorrhea -p st 3 weeks due to progesterone Probable Evidence of Pregnancy Enlargement of abdomen Changes in skin, shape, and consistency of » Cervical mucus: ern due Compared to haracteristi during first half ofthe cycle ‘s contractions that are otis irregular j feeling that something is floating/ bouncing back inside } n Coen . = B-HCG levels (251U/ dee aaE | ‘ing at 60-70 days = hyperemesis gravic 8 ‘Compiled by Rosa Fides G. Mina (UPCM 2018) # aie pe 1c Ne peeseparately from another > te + Uterine soufflé - maternal pulse Perception of active y the examiner Ultrasound or radio! + Male ~ turtle sign + Female - burger sign 1 Spalding’ sign - overlapping of fetal skull bones due to liquefaction of rain 2. Exaggeration of 3. _Roberrs sign = fetus er + No actual cardiac enlargement but only slight dilatation & displacement upwards & outwards due to gravid uterus + ECG may reveal slight axis deviation, occasional T waves, lowering of T waves + in HR maximal on 7-8 mo. = 10 bpm * t inCO by 30-50% 1. __ Increase in maternal oxygen consumption 2. _Hypervolemia of pregnancy 50-65% (peaks by 7 mo.) > + in erythrocyte production > dilutional anemia ° renin > ee ae e Na& IO retention terone causes venous relaxation . : Dine effect of placenta « 1 diastolic pressure & widening of pulse pressure « High CO and decreased AV oxygen difference 4 ‘Compiled by Rosa Fides G, Mina (UPCM 2018)On 28h Wk. of gestation Chichesagealae cRNA) due to t Plasma volume & oxygen deman 2 bei - flow to heart from uterine sinuses, 1 HR due to pain and anxiety of or sudden f in venous return - mobilization of fluids from the interstitial space into the vascular compartment + Heart sounds: exaggerated splitting of SI, systolic & soft diastolic murmur, $3 i * BP; systolic minimal change but diastolic | due to | total systemic peripheral resistance, resulting in { pulse pressure maximal during 7 to 8 mo. + Venous pressure: elevated in lower extremities due to © T blood flow from uterine vein into inferior vena cava Pressure of gravid uterus on the pelvic veins resulting in edema of legs & haemorrhoids + Upward displacement of the diaphragm by 4m + f vital capacity, tidal volume, & RR + | functional residual capacity and residual volume of air * 1 airway conductance & | total pulmonary resistance Due to | broncho-motor tone as an effect of progesterone Gtrereintasts . + Progesterone effect _ + | responsiveness to CCK > duodenal & biliary stasis > pancreatitis > hyperlipidemia > cholesierol stones « Liver of pregnancy ~ large, granular cytoplasm w/ small lymphocytic infiltrations, vacuoles & swelling of Kuppfer cells ‘Urinary System odickidneysionstucsohypermophy. and RBRcausing, | renal vascular volume « Physiol ; marked {in diameter of ureteral — lumen, hy tility of its musculature, more pronounced & Reside . Fear to UTI due to progesterone & pressure changes 5 Compiled by Rosa Fides G. Mina (UPCM 2018)+ Norm; Endocrine Soe which Tema eaeneNP TONE. slight T in BMR, 2) 7 (from estrogen), 3) mild iodine deficiency i ism > 1 calcium for fetus + Hyperadrenal state € gland hyperplasia wit + Diabetogenic due to placental degradation of insulin & anti-insulin effects of Placental lactogen, estrogen, progesterone WEIGHT GAIN Te Trimester | 0-2 Ibs. 94 Trimester | _11-14 Ibs. 3° Trimester | 1-14 Ibs. Skeletal System Back pain due to lordosis & fT mobility sacral joints (relaxin) Hematologic System. a. Dilutional anemia > 1 volume due to (Tt plasma> 1 RBC] > qlabilialeeiadslasisen sa © eqenioneliconsulapon eames 1 fibrinogen levels, t plasminogen and fibrin degradation products d. tf plasma iron binding capacity (transferrin) Iron requirement (RDA = 27mg/day) © Total throughout pregnancy = lg divided as: = 300mg for fetus/placenta = 200mg excreted + 500mg RBC production ¢. Fe salts: fumarate (83% elemental iron), sulfate (20%) . Mesoblastic period ~ in ring embryonic period ee “liver nye e tic period 2 Herd period — marrow starts function atmo. major ste of blood Myfpation in adults 2 6 ‘Compiled by Kosa Fides G, Mina (UPCM 2018) ———Qed Trimester | _<12.5 g/dL 3 Trimester |_20 wks. EDC - 1 day of LMP + 7 days - 8 mos. +1 year 1. Fundal grip: What part occupies fundus? + Breech ~ irregular, nodular parts } * Cephalic - round 2. Umbilical grip: Which side is the back? + Back - linear, convex, bony ridge ~ Small parts - numerous nodulations 3, Pawlik’s grip: Engaged in pelvic inlet? ‘« Head not engaged - round, ballotable, easily displaced « Engaged ~ felt as relatively fixed, knoblike 4, Pelvic grip: Attitude of cephalic prominence? * Flexion - cephalic prominence same side as fetal parts = Extension ~ same side as fetal back sment i ‘Asses: me _——+-CRC. Blood type Rh factor, Pap smear, FBS, Urinalysis, Urine culture, 6 Rubella IgG, Syphilis (VDRL/RPR to screen > FTA-AP to confirm), Hep B (HBsAg). # ‘Compiled by Rosa Fides G. Mina (UPCM 2018)| Chilanwedia eG Sones & Gonococcal if HR, el i————| offered | 15-20 | Fetal aneuploidy ~ 11-147 15-20 wks | wks, Neural tube defects ~ 15-20wks | | Congenital anomaly scan -18-22wks [REE ee anomaly scan “18-22wks wks. 75g OGTT 29-41 | Syphilis, Chlamydia wks, Group B Strep - 35-87 wks. HIV ~ 36 wks. Chlamydia (+) - test of cure after 8-4 wks. of Tx HBsAg (+) ~ give Hep B Ig and vaccine Frequency of Visits Uncomplicated + Every 4 wks. until 28 wks. + Every 2 wks. until 36 wks, + Weekly until birth Complicated + Every 2 weeks until 28 wks. + Every 1 week until birth WHO * At least 4 visits @1" Tri, 26, 32, 38 wks. + 100-800 Keal/day ‘ tri: 0 Calories 20d tri: | 340 keal/day Be! wri: + 452 kcal/day_ Folic acia_| Normal: £00 ugids [Protein | 7lg/day @) Carbs T75g/day Fiber 28 g/day Fats Min 15-25 g/day Ca 1300mg/ Sae Single: Iron ‘Twins: 60-100mg/day : WOF: ; in vomiting in 1* Tri wil [Folate [0a 750ug/day (14-18), 770ug/day (19-50) -50) Vit A (Retinol) | wor, Teratogenic @ >10,000 1U/day | (Thiamine) 1.4mg/day [(Riboflavin) L4mg/day | [(Pyridoxine) 2mg/day 8 ‘Conspiled by Rosa Fides G. Mina (UPCM 2018) fe “htToug/day ‘2amg/da ‘8Omg/day (14-18), 85mg/day (19-50) T5ug/da SE ese] Maternal age: <18, nullipara >35yo Maternal Ht: =/< 60in/I58em Obese ‘ocial factors: single, unwed, working, low economic status, diet, Smoking, drugs, alcohol oe * OBHistory 1.” Multiparity 2. PROM, IUGR 3. Premature labor 4, Macrosomia 5. — Multiple pregnancies 6 AF abnormalities 7. UTI, Diabetes, HPN 8. Thyroid disease, PTB 9. — Uterine/ovarian disease 10. Previous CS 1. Abnormal presentation 12. Placental abnormalities Headache ~ i BP 1 2. Blurring of vision - inc BP 3. Nausea & vomiting ~ inc BP 4 5 Facial edema ~ inc BP Abdominal pain - hepatocellular necrosis in HEELP, abruptio placenta, premature labor 6. Dysuria - UTI 7. Decreased fetal movement - FDIU 8, Vaginal bleeding ~ placenta previa, PROM 9. Vaginal discharge ~ vaginal infection 10. Fever - infection romoposterior diameters: ster : caer conjugate: Il cm (DC ~ 12) © Obstetric conjugate: 10 cm (DG ~ 1.5 10 2) 9 ‘Compiled by Rosa Fides C, Mina (UPCM 2018) « Borders: ANT; symphysis pubis, LAT — linea terminalis, POST - sacralDiagonal conjugate: 11.5-12.0 cm (measured clinic * Transverse diameter ~ 18cm + Right & Left Oblique diameter ~ 18cm Midpelvis — Plane of Least Pelvic Dimensions + Anteroposterior diameter = 11.5 cm Ocm ‘m + Anteroposterior diameter ~ 9.5-11.5 cm + Transverse (Intertuberous) diameter ~ Il cm * Posterior sagittal ~ 7 cm + Anteroposterior diameters: 12.5¢m ic uetry 1. Previous injuries or disease likely to affect the pelvis 2. Breech for vaginal delivery 3. Vaginal birth after cesarean section (VBAC) Soft Parts of the Pelvis wuscular part separating pelvic cavity from perineum; Levator (Puboccocygeus, lliococcygeus, Ischiococcygeus) + Pelvic diaphragm ~ helps in control of the external anal sphincter through the puborectalis & ischiococcygeus; also stabilizes joints Diagonal conjugate > 11.5 cm Bispinous diameter > 9.5 cm Pubic Arch > 90° Coccyx: moveable Sacral inclination: posterior Sidewalls: divergent Sacrosciatic notch: wide (2 % fingers) Curvature: hollow ~ Best indication of adequacy: trial of labor SENoveewr 10 ‘Compiled by Rosa Fides G. Mina (UPCM 2018)a ae peeiprewe | soge Stim | four | tap 3 L 4 7 wes wos 20 FEY mon, ead =i 7 sz (osama bon aay sure tas aan aaapigg | "PO i 2 pam per eS, peas por Dory eam pur Joey pang b aoia! = : g 3 ermaad oy omy eoepmead ion pelo, oad rps g S 2 3 & sataaig wlouwey resdoup 0 wins gees TPs =5 & + fury 3 (Fos por aouer Spgas op pon may aogry poepa sen | xogrpporay | preamps i a nen g re per anczre dpigs | py por prea poorpuy masa por Jor] PAD PA noes | & s 2 ‘naire rasan Jonauea an = £ —— mpropeeiy | repeaps | pce | eee z & yess apo, moa Poy, aieys, 5 Cedi er Eee pevly Ere | miki mk hh hwa itu: + Relation of + Head is fexed, back is convex, thighs flexed over abdomen, legs bent at knees, arches of feet on anterior surface of legs * Relation of s to lon; 1. Longitu ~ long axis of fetus parallels the long axis of uterus (Pres'n: Cephalic, Breech) 2, Transverse lie (1X) ~ long axis of fetus perpendicular the long axis of uterus (Pres'n: Shoulder) 8. Oblique lie - unstable, becomes either longitudinal or transverse Ectal Presentation 1 Werex Occpu) ‘+ Mest common because uterus is pyriform * Posterior fontanel is presenting part + Head fully flexed + Shortest AP diameter: suboccipitobregmatic - 9.5 cm b. Sinciput (Military) + Bregma/anterior fontanel is presenting part + Head partially flexed, transient * Occipitofrontal diameter ~ 12.5 cm <. Brow + Head partially extended, transient + Longest AP diameter: Occipitomental plane ~ 18.5cm . Face + Head fully extended + Submentobregmatic diameter - 9.5cm + Indication for CS delivery a. Frank ~ thighs flexed over abdomen, legs extended over anterior _ body, feet near head b. ‘Coasnlete ~ thighs flexed over abdomen, legs flexed over thighs, feet at yuttocks, level Single footling ii, Double fooling 3. jer (Acromion) : - id ~ prolapse of the fetal hand alongside the presenting vertex or foot alongside the head one or both thighs extended, legs and feet below buttocks 12 ‘Compiled by Rosa Fides C. Mina (UPCM 2018) BUNUN weS 3 Se: a Be = a = s = « Relation of the point of direction to one of the 4 quadrants or to th ‘AP/transverse diameters of maternal pelvis os «Points of direction: Occiput in cephalic, Mentum in face, Sacrui ‘Acromion in shoulder im in breech, Left occiput transverse (40%), Right occ’ (20%), Occiput posterit San cere o0n ight occiput transverse 1. Serial measurement of maternal weight 3 Fundic height in determining estimated fetal weight ‘Rough estimate at >32 weeks: Fundic ht of 1 faim sg 00 30 cm = 6 - 6 % Ibs. 31cm = 6X - 7 Ibs. + 32cm =7~7 % Ibs. McDonald's Rule: AOG wks. = D (in cm) x 8/7 Johnson's Rule: Fetal wt. in gms = (Fundic ht in em ~ n) x 155; n= 12 if station below spines, 11 (engaged) if station above spines (unengaged); use n+l if >200Ibs 3. Fetal heart tones: NV ~ 110-160 bpm 4. Fetal activity acceleration determination: Gaunt fetal movements starting 1 hour after meals and before bedtime: NV "go to OBAS if <3 moverents/hr. Real time ee = Biophysical Scoring System Bese on next page 1. Fetal tone - 7.5-8.5 wks. (I to appear, last to 2. Fetal movement - 9 wks. 3. Fetal breathing - 20-21 wks. 4. ae HR-R ~ 38 wks, (Ié to disappear in hypoxic states) // BPP done at H assess the uteroplacental circulation and | eer nicaecel umbilical artery of the fundus = selenIEE a oxyrocin challenge + Measure of uteroplacental function 3 « Evaluates the reaction of HR td contractions induced by nipp! stimulation or oxytocin «Done when 8 contractions/10 mins 13 ‘Compiled by Rosa Fides G. Mina (URCM 2018) eee eABATTOP - G-0 ‘SIM TE< J! APALOP — f ‘SAM OR< JE ABATTEP — 9 ‘sym _£g< JLABAOP — AAV [eULIOUGE O} aNp g “SdUTEANSsEaI — AAV [CULIOU YIM O1-8 ‘Sd anys sourjd avjnatpuadiad -$ av 10 Aav Guru [> 40 siayv0d VON | 1 somnseour anenpend, ey AV Jo iypod Paseay ay Get t | SUTUL Og UUM S05 2 39s g[> 10 wdq o> | 2 | | yo uonesajaooe 10 soposida g > | 981703 urdq st< J eerie ISN 2aney, 3 | | 8 ie ig ; 3 uo} (-) 10 ‘uorsuaIxe [[Ny yun squay Jo UorXaYy 3 | urquijjo waweaaour ‘uorxay | or auoy, peiag 4 | ob mantas wore ys weg | 1 eo] i has ones) ume] soposida 19093 10 % surw 0g Ut sJusu9AOU Lj mea cewciene’ idle aa aas Qg> spostda 10 1uasqy Jeurwopqe rn 0 aposi sea] TW reg (0 = 24096) jewuouqy (G = 24098) [eULION eae a ee th ob ooInterpretation Fe ive ~ no late icant variable deceleration a een highly predictive cg 2, Positive ~ consistent and persistent late decelerations (>50%) of FHR absence of uterine hypertonus or supine HPN, even if contraction frequency is fewer than 3 in 10 3, Suspicious ~ intermittent late decelerations or significant variable decelerations 4, Hyperstimulation ~ FHR decelerations that occur in the presence of contractions more frequent than every 2 mins or > 90 secs 5. Unsatisfactory ~ frequency of contractions is less than 3 per minute or poor tracing b. Non-stress test : Bea 1. Reactive ~ at least accelerations of at least 15b} PEO 20 Ha Highly predictive orinirentctins sacmcate 2, Non-reactive ~ if otherwise; may imply fetus is acidotic, asleep, or drugs were given A ) = full bladder acts as acoustic window, pushi ‘out of pelvis & displacing bowel superiorly E pon sei gestational sac (5-6 wks) es if ectopic pregnancy is suspected 2. Detection of embryonic/fetal life (Fetal heart movement at 7WKs) & # of fetuses . Evaluation of complicated early pregnancy such as retrochorionic 3 hapeimma sete ome abortion 4 pregnan: 5 ation of| D. 1. Fetal tone), number and presentation an ization oF 4. Evaluation of fetal anatomic structures (reversal of fetal diastolic blood flow in the umbilical artery indicates a severely com fetus) -reee rane cack eae coe «Cervical softening but 15 Compiied by Rona Fis G. Mina (UPCM 2018)for Labor + Uterine ess of labor - cells, ; number and size of gap ju myometrial J A Ness to requency of “Hrocesof labor contractio it and dilatat tal expulsis BHASE¢:Invelition co rine involution to prevent hemorrhage {Cervical repair - restoration of fertility y Breast feeding — lactation and milk ejection + Regulators: uterotonins 5 Sai TAai to produce functional elements that and cervical softening cause PARACRINE SYSTEM * paracrine arm ~ amnion, chorion leave, decidua parietalis J Forebag ~ amniotic fluid trapped between the leading surface of the presenting part and the inner surface of the lower pole of the amniotic sac, PG [evels are 10x 1; created by cervical dilatation and effacement « Hindbag - upper compartment, contribution of fetal swallowing, urination and fetal lungs Signs of labor L oa Baby drop - | fundic ht due to formation of lower uterine segment allowing fetal head to descend, also ; in amniotic fluid sgn ee Hicks Contractions ~ painless, unpredictable, sporadic, , with no cervical dilatation Ssebloody shew “spontaneous release of a small amt of blood-tinged mucus mi Vi extrusion of mucus plug ‘mechanical stretching of cervix enhances uterine activity ¢ thinning of LUS asin obstructe mes very prominent > uterine rupture Effacement, Station BISHOP'S SCORE - predicts whether induction of labor will be required + Uterine : Call PEDS for Parturition) 1. Cervical dilatation 4. Cervical position 2. Cervical effacement 5. Fetal station 16 ‘Compiled by Rosa Fides G. Mina (UPCM 2018)« Obliteration/taking up of the cervix * Shortening of the cervical canal from length of 2cm > circular orif paper-thin edges fice of /= lem/hr. Started at 6mU/min to at increments of 6ml/min ql5 mins but not to exceed a total of 60mL/min WW¥vwv * Average duration: Nullip: wultiparas = 20 mins +» Contractions last f¢ * Monitor: Low risk ~ ever High risk - every Smin ‘+t Maternal plasma oxytocin levels + Dorsal lithotomy t pelvic outlet 1. Delivery of the head + Crowning ~ head encircled by vulvar ring ___+Episiotomy ~ prevents perineal lacerations 2. Ritgen’s Maneuver 20 Compiled by Rosa Fides G. Mina (UCM 20)«Controls delivery of head with extension so smallest di head pass over introitus Mi « When vulvar opening is Scm wide, towel draped hand ted to exert forvard pressure on the chin of fetus throng ge h the lameters of perineum + thier hand is placed on occiput $ prevents extension episiotomy & fetal contamination \ 8, Nasopharyngeal toilette nafer delivery of head, face of fetus is wiped and nares & thr quickly suctioned oat « To prevent aspiration of amniotic fluid and blood 4, Nuchal cord care + Mechanisms of placental expulsion Schultze Mechanism ~ starts at central portion, placenta descends by anes along thus forming some form of an inverted sac 2 ‘Dirty Duncan” ~ starts at periphery, placenta lescends to the vagina sideways and blood escapes 1 leg riecenalaeet sign ~ uterus becomes globular and firmer 2, Sudden gush of blood into vagina 3. Uterus rises in abdomen ‘4, Umbilical cord lengthens as placenta descends « Lacerations of the vagina & perineum 1* degree ~ fourcheite, perineal skin, vaginal mucosa, but not underlying fascia and muscle ‘264 degree ~ invoives fascia and muscle of perineal body but not anal ace aeaben ‘ ~ from vaginal mucosa, peri , and fascia up to an: sphincter but not the 4" degree - up repaired before vaginal mucosa) + Types of episiotomy 1. Median ~ less painful, easier to repair, heals faster but may extend to rectum if perineal body is short 2. Mediolateral ~ more commonly used, for less severe lacerations erg sei suture 2. Vaginal mucosa ~ interlocking sutures until lower end of hymenal ring, start lem above angle of mucosal defect at ‘Compiled by Rosa Fides G. Mina (UPCM 2018) See ee ee4, Subcutaneous and fascial layers — continuous sutures 4. Skin -subeuticular or interrupted sutures, sewing ~ itis one of the methods that can be used to contr ree caginal lesion. Its done by apposing normal tiesue with he, bleed “bleeding site and in effect, serve as a tamponade for the the am to coverewing may be done using a continuous running locked ae Meed. Oversehs ta control an actively bleeding vaginal lesion inchide packi Other Serial embolization. Packing and Harmful Practices ‘Oxytocin ai any time Sunained bearing down before full dilatation Massaging & stretching of perineum 4. Fundal pressure 5. Lithotomy 6. Supine 7. Rectal exam 8. X-ray pelvimetry @. Manual exploration for retained placenta 10. Lavage of uterus “eaetepecteenrctnee + Management: uterine massage, ice packs, oxytocin per + Vaginal bleeding >500cc w/in 24 hrs. post~ : rarer 0 post-op (early), >24 hrs. post-op (late) Cause Clinical findings: Management ‘TONE: Userin Soft uterus palpable above umbilicus; RF: ; atony rapid/protracted labor infection. MgSO, | “SoG Tviniodoml, “ 200 IV in 10 TEAR: Genital | Contracted uterus, visualizable lacerations; RF: lacerations uncontrolled vaginal delivery, LGA, ‘Suture under anesthesia E _—forcepe/vacuum __ TISSUE. | Manwal uierine aaa Missing cotyledon exploration, UTZ: ou Foilure to palpate : sa ae uterus; dark, beefy-appearing | Uterine replecerent 22 ‘Compiled by Roxa Fides G, Mina (UPCM 2018) mass @ introitus aesdelivery of placenta productive organs to o Tame aftr Ae epnant conditio - _—e rm Hk, yellowish alkaline fluid, high protein and mineral colostrum = Ke no! cco less sugar, larger fat globules vine involution cterine size J by 1-2em/day) first mil + Uieritt level of umbilicus ~ after placental delivery Sat symphysis pubis ip eenirac 1€ to: uterine atony, clot formation at «Failure of ute tal site, retained placental cotyledons, inadequate drainage thrombosed placent of tissues infection ‘due to vascular and lymphatic engorgement, and not due to milk fever (<24hrs) Posipartum Frver(PPD — usual postparwumdays) [PED] Cause Clink igs MoMT pe Mildemod fever, mild reso | —pamonary IND Atelectasis | auscultation; RF: emergency CS monary exercises, ce Rleka ibs with gen anesthesia” ambulation - igh fever, malaise, CVA 12 WATER: UTI tenderness, (+) urine CS; RF: | Cephalosporin 1-2 ¢ PO 6, indwelling Foley, — JE Mod fever, uterine tenderness, | Clindamycin 900m 1V 8, 2-3 | WOMB: Endometritis ‘Gaba findings Gentarncin 500mg E03 Spiking fever despite abx, | Aba for cellulitis, incision 45 | WOUND Infection | wound erythema or fluctuance, | and drainage, saline packs, wound drainage secondary closure ‘Wide fever swings despite abx; WALK: septic pelvic normal abd/pelvis; RF: eae a thrombophlebitis emergency CS, PROM, eae oe prolonged Jabor_ Tnilateral localized erythema, 7a Mastitis ‘edema, tenderness; RF: nipple Abx, drainage trauma RBURBUUYY Cardiac output returns to normal by 2nd wk. - Urinary retention in the Ist 24 hrs. due to edema & congestion of vulva, urethra & bladder trigone; edema and reflex spasm of slice ise siany Diuresis is greatest from 2nd - 5th day Lochia ~ discharge from uterus during puerperium; odor is heavy and fleshy but not offensive, lasts 4-8 wks. 1. Lochia rubra - first 3-4 days, bloody 2. Lochia serosa - next 3-4 days, paler & pinkish 23 Compiled by Rosa Fides ©. Mina (UPCM 2018)g,Lochia Alba - from 10th day onwards, white/yellow-white ‘White due to Jeukocytes, | fluids soul lochia - 2"to poor healing, infection, ret | Gee pains — contractions of the flaccid uterus io lane afte Ping fragments and blood clots expecially in acne Of the rerense during breast feeding ieee ens® “ation due to inactivity, decreased intraabdominal pr | . Gen ip Pe pei perincseo ‘inal pressure after | Weight loss | ‘oave wt loss of 5 kg immediately post-op ‘Add’! loss due to diuresis & skin loss | | ‘ ‘blues lation ovulation i Spaayel n (of 1Smins to PRL inhibition of GnRH (@-18mos) rospa 2 ae cup in 4-6wks, 75g OGTT at 6 wks., BP at 12 wks, Pap © 1. Written BF policy 2. Train staff 3. Inform women benefits and management 4. Initiate within | hr. of birth 5, Show women how to BF and sustain lactation 6. Pure BF 7. Rooming-in 8. BF on demand 9. No artificial pacifiers 10. Support groups & referral x 5 Baseline Rate: 110-160 bpm Baseline Variability: 6-25 bpm (moderate) No late/variable decelerations Early decelerations (+)/ (-) emit ase ee 20 mins . : 215bpm for 15 secs ~ 2 mins + 70X Ampullary, 12% Isthmic + Heterotropic pregnancy ~ simultaneous intrauterine & ectopic pregnancy RISK FACTORS ‘Abnormal FT anatomy 2° STDs, adhesions Salpingitis ART, POCPs Surgeries for fertility restoration, sterilization, Myomas, adnexal masses |. Smoking Prior ectopic pregnancy oR eee SYMPTOMS (Classic triad): 1. Colicky abdominal pain Ame re 2. Amenorrhea of about 6 wks. followed by 8. Minimal vaginal bleeding 9 ri ny hd atton. SIGNS: ( 1. MC: Wiggling tenderness 2. Uterus smaller than AOG 3. Fullness of retrouterine cul-de-sac due to hemoperitoneum DIAGNOSIS 1. Empty uterus with serum 8-HCG 21500 mIU/mL 2. Low progesterone (> 25ng/mL. excludes ectopic) 8. TVS —(-) gestational sac, (+) trilaminar endometrial pattern, (+) adnexal mass MANAGEMENT A. Medical 1. Indications: <6 wks., spotting/hemorrhage 9. Rapid uterine growth 3. Theca lutein cysts (enlarged ovaries) 4, Nausea & vomiting, hyperemesis gravidarum, hyperthyroidism (t {T4, {Ts 5 ‘SnowstorniPyppearance (complete); thickened, multicystic plac im feature Partial Mole [Complete Mole iKaryotype [69XXX or 69 XXY [86 XX ical presentation [Diagnosis [Missed abortion [Molar gestation [Uterine size [Small for AOG [Large for AOG jeca-lutein cyst [Rare [25-30% Initial hCG levels <100000mIU/mL /100000mIU/mL Medical prob IRare [Uncommon. Rate of > GIN 1-5% 15-20% Pathology [Embryo-fetus JOften present [Absent (Amnion Often present [Absent illous edema [Focal jidespread TFocal, slight to [Slight to severe imoderate ae Mild Marke: [P57 immunostain) () =~ MANAGEMENT LL Pre-op eval of preeclampsia, hyperthyroidism, IDA, electrolyte peop mets (CXR for lung mets) ical Fe reson ot tathac progasicy: cucion caretiane W/ C=SE Oe dilatation, or hysterectomy (if >40yo or complete family size) 28 Compiled by Rosa Fides G. Mina (UPCM 2018)ee 3, IVaccess for blood loss replacement i. WOF respiratory insufficiency, pulmo edema, embolisin $ Aspiration of larger theca lutein cysts 5 post-op 6-hCG monitoring within 48 brs. then ql-2 wks. until undetectable nda 7. QGp for lyr to prevent pregnancy (avoid T -hCG) 7 Pollow-up exams: p-RCG levels q2wks for 3 mos, gl ? for 1-2 yrs. qlyr after; pelvic cat gw UME n SPAT eae wT indications for Immediate Referral toa Trophoblastic Disease Specialist ticarigh p-hCG levels > 4 weeks post-evacuation (serum level of 30,000 milU/nL) 7 elevated p-hCG titer at 14 weeks post-evacuation .CG of 10% or greater (2 consecutive determinations) suing B-hCG values (<10% fall or rise) at any time after evacuation Snimum of 8 consecutive weekly determinations) Clinical or histologic evidence of metastasis at any site Elevation of a previously normal 8-hCG titer after evacuation provided the diagnosis of pregnancy is excluded Chemoprophylaxis for H. mole Shay be useful for patients at high-risk of post-molar GTD and when post- evacuation surveillance is doubtful*. The ff. features put a patient at risk for post- molar trophoblastic disease. + Advanced maternal age 2 85 y.0. Gravidity of 24 Uterine size larger than age of gestation by 2 6 weeks Serum p-hCG titer 2 100,000 mIU/mL Theca lutein cyst(s) 2 6 crn Presence of any medical complication associated with inc. trophoblastic proliferation: preeclampsia, thyrotoxicosis, pulmonary insufficiency & + Poor patient compliance to ailaw-tis ae *Use of chemoprophylaxis in situations of poor follow-up has been questioned. It requires monitoring due to the side effects. *Points against prophylaxis: toxic side effects, increases in WHO score — ae yew Ss @ hypersensitivity or liver toxicity, Actinomycin D may be given- a ae i to chemoprophylaxis: + Hemoglobin <100 mg/dL, «Any active infection hematocrit <0.20 © TRr/renal dysfunction + WBC count < 8 x 10? = Known to + ANC S15 chemoprophylactic drug * Platelet count < 100 Bie‘schedule of monitoring for H. mole AP sfver molar evacuation, all patients must have serial pic : malignant degeneration (Level III, GPP). Serum p-hcc jon oMtoring to detect 3 level is measured, 1 1 week after molar evacuation, then 2, Every 2 weeks until level becomes normal (<5 miU/mt) 8 After 8 consecutive biweekly normal levels, the moriteyin month for 6 months: then Bis every it 2 monthly intervals for the next 6 months to ens Flies veneie wrdiecctable Sor | year following remission are NCC evacuation of molar pregnancy, B-hCG levels usually disapreet 10 weeks. After normal delivery or miscarriage B-hCG leeepne undetectable within 8-6 weeks. More than half of patieneess eo complete regression of f-hCG to normal within 2 monka ne ea evacuation. Continue monitoring p-hCG until it is undetectable for 1 year. Pregnancy is allowed after 6 months of normal serum hace level. ETIOLOGY oe +X follow H. mole +X follow miscarriage/tubal pregnancy bs | + follow preterm/ term pregnancy CLINICAL FINDINGS OF GTT 1. Irregular bleeding with uterine subinvolution 2. Aggressive invasion, metastasis DIAGNOSIS 1. Plateau B-hCG for 4x in 3 wks. (days 1,7,14,21) 2. Rise in 6-hCG >10% during 8 weekly consecutive measurements in 2 wks (days 1, 7, 14) 3 8. Serum §-hCG detectable for 26 mos. 4. Histological diagnosis of choriocarcinoma INVASIVE MOLE / Chorioadenoma destruens + Invasion of trophoblast and whole villi into uterine wall + Tx single-agent chemotherapy with methotrexate (5-day: 0.4-0.5 mg/kg IM g or IV OD, weekly: 50mg/m* IM or IV); hysterectomy if complete family size or 285 CHORIOCARCINOMA + MC type ff term pregnancy or miscarriage {vades myometrium & BV > necrotic hemorrhagic masses or nodules + Tx: single or combination drug therapy, Hysterectomy lacoMuG COMBINATION 8 'TaPY: Hys ~0.3-0.4 mg/kg BWiday IM D ~ 10-12 ug/kg BWiday SIVP 30 ‘Cotnpiled by Rosa Fides G. Mina (UPCM 2018)a Cyclophosphamide ~ 3 mg/kg BW/day PO, or r Chlorambucil ~0.2mg/kg BW/day PO EMA-CO CHEMOTHERAPY Course 1 (EMA): Etoposide, methotrexate, actinomycin r Course 2 (CO): Vincristine, cyclophosphamide PLACENTAL SITE TROPHOBLASTIC TUMOR + From implantation site intermediate trophoblast + Tx hysterectomy & adjuvant multidrug combo EPITHELIOID TROPHOBLASTIC TUMOR « From chorionic-type intermediate trophoblast » Tx: hysterectomy, but resistant to chemotherapy gr FIGO ANATOMICAL STAGING for GTN. Stage I | Confined to uterus Extending outside uterus, but limited to genital structures Stage II | (adnexa, vagina, broad ligament) ‘Stage II Extending to lungs, w/ or w/o genital tract Stage IV All other metastatic site cE WHO Prognostic Scoring System. Scores. Low risk: 0-6, ficient High is waa corte a 908 Pp Conall by Rou Fey. Mina (URCM 201) ‘ Be « seed.fae $$ ‘TYPES : 1. Total - placenta covers internal os completely z 9. Partial - internal os partial covered by placenta 3. Marginal ~ edge of placenta is at margin of internal os 4 Low: lying - placenta is implanted in lower uterine segment but outside 9- cm perimeter around internal os RISK FACTORS : 1. Multifetal gestarion, large placentation 9. Maternal age >35 8. Prior CS 4. Smoking 5. t MS-AFP DIAGNOSIS 1. Painless, profuse, sentinel (w/o contractions) bleeding in third trimester due to migration 9. TVS for placental localization 8. IE only if deliver planned (double set-up) -Abruptio Placenta + Premature separation of normally implanted placenta + Rupture of spiral a. > retroplacental haemorrhage ETIOLOGY 8. External wauma > external or internal version 4. Short umbilical cord 5. Sudden uterine decompression CLINICAL FINDINGS F 1. Sudden onset abdominal pain, vaginal bleeding and uterine tenderness 2. Diagnosis of exclusion 3, +/- hypovolemic shock. DIC, couvelaire uterus/ uteroplacental apoplexy » AKI, Sheehan syndromeClinical Classification of Abruptio Placenta Mild Moderate Severe ——— Mother [Normal CVP | + pulse, 1 CvP Shock | hypotension, : fetus Normal FHT | Signs of fetal distress| Fetal distress or death] Complication |None, good urind None, marginal UO | Renal failure, output re — coagulopathy Uterus Trritability, pain | Irritability, pain, | Severe pain & tenderness, tenderness severe tenderness tetanic contractions [Bleeding | <500mL 500-1000mL >1000mr Placenta 600 g Placentomnega ata ~ accessory lobe outside main disc hhorial placentas ~ membranes do not insert at disc Exi=\Circummarginate ~ membranes without thickening 5. Circumvaliate - membranes arise from a cup Placenta Accreta Placenta accreta vera ~ villi contiguous with myometrium Placenta increta - villi invade myometrium Placenta percreta - villi penetrate serosal surface of myometrium Total accreta - adherence of all cotyledons y Partial accreta - adherence of few to several Focal accreta ~ adherence of a single cotyledon tis t 2 of 1. Fever >38°C 2, Tachycardia (fetal and maternal) 3. Maternal leucocytosis POLYHYDRAMNIOS + Amniotic fluid of >2000mL + Clinical correlates: Gl tract abnormalities, anencephaly/spina bifida, DM, erythroblastosis fetalis « Diagnosis: measure largest pocket of AF on UTZ Mild: 8-llem Moderate: 12-15cm oSevere: 16cm + Amniotic fluid index (AFI) - summation of largest vertical pockets of 4 quadrants of uterus, NV: 5-24cm (AFI >24cm) OLIGOHYDRAMNIOS + Paucity of amniotic fluid at term (<500mL) * Clinical correlates: IUGR, dysmaturity syndromes, renal agenesis, obstruction + AFI 1.1 mg/dL. or doubling of lpreeclampsia [serum crea in absence of other renal dse ired li jon: Elevated serum liver transaminase 2x normal levels rAny of the fF: |BP: 2160 sys or > 110 dias, 2x 4 hrs. apart at bed rest wu « Jampsia_|Impaired liver function: RUQ epigastric pain (hepatocellular th severe |necrosis) or hepatic transaminase levels 2x normal features (Pulmonary edema “visual disturbances: headaches/scotomas are |premonitory symptoms of eclampsia Eclampsia | Preeclampsia + convulsions before, during or after labor nic HPN [HPN of any cause predating pregnancy: BP 2140/90 before regnancy, before 20 wks. AOG, or both. ceersdaeieaa ic HPN with associated preeclampsia; worsening baseline posed | FPN with new-onset proteinuria/other findings associated with [preeclampsia RISE FACTORS . Maternal personal RF - primiparity, primipaternity, Hx of preeclampsia, ey, FHx of oe ae age 240yo; smoking 1 pak Cae . Maternal % > an periodontal di |, APAS, SLE; renal dse, mater! i 3. Placental/ Fetal RF ~ multiple or molar pregnancies PATHOPHYSIOLOGY + Trophoblastic hypoperfusion Compiled by Rous Fes G. Mina (UPCM 201)in denervation & loss of muscular and elastic. components causing. oe results «ingrowth of trophoblastic cells into the tunica media of spiral arte Is, tion & elongation to a “corkscrew or saw-toothed” cone’ OF | _ eee Syclipieficiency + abnormal arteries result ina state of lange no foconst A ive PREDICTORS OF PREECLAMPSIA 5, Mean arterial pressure: ave pressure in arteries during one ca = MAP = diastolic (systolic-diastolic)/3 Mg one cardiac cycle 6. Biochemical markers: AFP, fibronectin, total fetal DNA, hC is activin A, PAPPA, kallikreinuria -G, inhibin A, a 7, Urerine artery Doppler: uterine artery patching bet 18-24 wks. AOG PREVENTION 1, Low dose aspirin starting <16wks AOG 2. High dose calcium: 3 MANAGEMENT | 1. Oral Antihypertensives ‘2. Beta-blockers: Labetalol - 200-2400mg/day BID-TID divided doses PO a b. Calcium channel blockers: Nifedipine ~ 20-120mg/day PO ¢. Methyldopa: 0.5-3g/day BID-TID divided doses PO 2. IV Antihypertensives a. Hydralazine (DOC) IV of 5 or 10mg q20-30mins b. Clonidine (2" DOC) IM 75-150meg 8. Therapy for acute-onset severe HPN a. Labetalol 10-20mg IV, then 20-80mg q20-30mins or 1-2mg/inin IV infusion b. Hydralazine 5mg IV or IM then 5-10mg q20-40mins, then repeat QShrs; 0.5-10 mg/hr. IV infusion c. Nifedipine 10-20mg PO then repeat in 20 mins, then 10-20mg PO q2-6hrs 4. DSW 90mL + Nicardipine 10 mg, 0.Img/mL sol'n at l mg/hr. ___+Img/hr. every hour up to 10mg/br. 4, Seizure control: Magnesium sulfate a. 1V infusion: g i, Loading dose: 4-6g in 100mL over 15-20min ‘ii, Maintenance dose: 2g/hr. in 100mL 1V infusion iii, Monitor: DTRs, serum magnesium if serum crea 2img/dL iv, Discontinue 24hrs after delivery: b. IM injectior i. Loading dose: 4g 20% sol'n IV at $ 1g/min ii 10g.0f 30% sol'nt IM, give J (6g) per upper ower of exch Dutock iii If persisting after ISmins, give up to 2g 20% soln 1V at Ie/min 36 ‘Comnpiled by Rosa Fides G. Mina (UPCM 2018)iv. Maintenance dose: Give 5g 50% sol'n in al qghrs after in alternating buttocks y. Monitor: (+) patellar reflex (, RR212min, peeeiont aie UO 2100mL in vi. Discontinue 24hr after delivery c, MgSO« Toxicity ~ give Calcium gluconate 10ml. 10% sol'n IV ©. Plasma magnesium levels maintained at 4 to 7 mEq/L, 48 to 8, mg/dL, or 2.0 to 3.5 mmol/L . « DTRs disappear at 10 mEq/L (12 mg/dL) reathing weakened if > 10 mEq/L « Respiratory paralysis/arrest if > 12 mEq/L 5, Other a nvulsants: ‘Loading dose: 10mg IV over 2 mins Maintenance dose: 40mg in 500mL normal saline IV infusion b. Phenytoin - used after diazepam, prevention 6. Induction of labor or CS if vaginal delivery is not imminent or there is feta compromise 5 CRITERIA: Overt DM: Gestational DM 5 FBS 126 mg/dL. ‘Atleast 2ofthe | 75g OGTT RBS 200 mg/dL. ff: HbAIc 6.5% 92 mg/dL peacoat G.lmmol/L)_ MgOGTt,3- 200mg/dL hour ae 180 mg/dL i poe (10 mmol/L) 140 mg/ a-hour .8 mmol/L) GENERAL INSTRUCTIONS FOR OGTT 1. ‘The patient should be on at least 3 days of normal unrestricted diet containing a minimum of 150 mg carbohydrate per day prior to the test. 2. Testing should not be done while the patient is sick or under stress oF 08 aN ons that can increase blood glucose level. I . No smoking is permitted during the test. 4. The patient should remain at rest during the test. 5. Glucose solution must be consumed within 5 minutes. i ee Bee eriscs ts consequence of actice of PES Insulin’ , progesterone , does hot cross placenta + fetal h r+ DM Screening: first visit, 24-28 wk, 32-34! wk. Connie by Rona Fides. Mina (UPCM 3019)we a2mUcae ae se L $ 3. 4 5 6. MANAGEMENT L 2. 3. 4 5. 6. MATERNAL EFFECTS 1, Preeclampsia, Coronary heart disease 9, Difficulv/operative delivery 3. Bacterial Infection 4. Diabetic nephropathy, retinopathy, neuropathy 5, Diabetic ketoacidosis FETAL EFFECTS ‘Abortion Preterm labor and delivery Polyhydramnios Macrosomia, shoulder dystocia Congenital malformations | Unexplained fetal demise Goals: FBS <95, I-hr <140, 2-hr <120mg/dL |. Medical nutrition therapy . Weight management Low glycemic index food Lifestyle changes |. Medical Tx: Regular or rapid-acting insulin . —— FACTORS: race, heredity, age >85, parity >4, maternal size & nutrition, use of ovulating drugs (clomiphene. Gonadotropins) TYPES 1. Double ovum with 2 chorions, 2 amnions, 2 placentas 2. Double ovum with 2 chorions, 2 amnions, } placenta 3. Single ovum with | amnion, 2 chorions. 1 placenta 4. Single ovum with I chorion, amnion and placenta MATERNAL COMPLICATIONS 1. Discomfort, difficulty moving 2. 1 severity of N&V, anemia 8. f risk for previa, abruptio, malpresentation, postpartum hemorrhage, PIH, preterm labor FETAL COMPLICATIONS 1. 1UGR 2. Anomalous anastomotic vascular connections > twin-twin transfusion > larger twin develops hydramnios & polycythemia, smaller twin develops oligohydramnios & anemia 8, intertwining of umbilical cords BB ‘Compiled by Rosa Fides G, Mina (UPCM 2018)following death of win $ iGeliion and lnterlocking (chin to chin if both cephalic presentation) 1m with 42 wks. AOG MATERNAL COMPLICATIONS 1. Difficult deliveries (FWe >4.5kg, arrest of dilatation, prolonged 2» stage marked caput & molding) ee el eee 2. Operative deliveries Fetal Signs of Posten Pregnancy 3. Postpartum haemorrhage + Old Man Faces 4. Failed induction of labor : FETAL COMPLICATIONS eae L. Seillbirth 2. IUGR or Macrosomia and shoulder dystocia 3. Fel distress &hypoxia 4. Meconium aspiration syndrome MANAGEMENT 1. Assessment of true gestational age 2. Patient counselling re: induction of labor vs. conservative mgmt. 3. Antepartum surveillance tests 2x/week: fetal movement counting, NST> CST, fetal acoustic stimulation test, BPP Ue. prenatal visit Bee fu/r. with 1 or more organisms in 2 consecutive midstream - terized specimen in oe ; -ahee a rie lurnalysis (not sce eT anes etiologic agent: E. coli Niece 100mg qBhrs x 7 days (avoid >35wk AOG) ASYMPTOMATIC BACTERIURIA 2 ‘A. Diagnosis ~ Screening done at Tx 40 Compiled by Kosa Fides C. Mina (UPCM 2018) tractions are rare, then vith ES 7 Te= cystitis a is - Screening done at I*' prenatal visit 4 cal urinary frequency, urgency, dysuria, bacteriuria a ja of 2 8 pus cells/mm! (uncentrifuged) or 25 pus cells/HPF ( pb reatment=7 days of Abx ee PYELONEPHRITIS es = Screening done at 1" prenatal visit * Chills, fever, flank pain, N&V, w/ or w/o signs of lower UTI, CV. pyuria 25 pus cells/HPF (centrifuged)) and Bacteriuria (210,00 ropathogen/mL) 20 . . os stain, urine C&S, blood cultures ‘A tenderness 0 cfu of B. Treatment — admit, 14 days of Abx Intrauterine Growth Retardation CLINICAL IDENTIFICATION 1. Previous undergrown infant in multipara 2. Slowing in fundal measurement ( 2hrs. of pushing in multiparous women without epidural b, 28 hrs. of pushing in nulliparous women without epidural ¢. 28 hrs. of pushing in multiparous women without epidural d. 4 hrs. of pushing in nulliparous women without epidural a ae 1. Different presentations a. Breech presentation — Mauriceau Smeliie Veit Maneuver; Pinard Maneuver for frank breech b. Face presentation ~ Do CS, do not attempt conversion to vertex c. Brow presentation d. Transverse lie - Do vertical CS, may attempt external version ¢. Compound presentation - Watch if arm retracts out of the way, if not, push upward & head downward by fundal pressure £. Persistent occiput posterior — manual rotation then spontaneous delivery, forceps or vacuum with episiotomy, or CS if head above inlet g Occiput transverse position — give oxytocin, manual rotation or forceps rotation & delivery h. Shoulder dystocia - McRoberts Maneuver 2. Fetal developmental abnormalities 2 a Macrosomia: FWt >4500g 2° DM, multiparity, large parents/ genetic, post-term pregnancy b. Hydrocephalus - Do cephalocentesis & CS ©. Large abdomen ~ transabdominal decompression 4. Conjoined twins| 2n4fo20) 2ar8 eur | ‘urordxo 2a18 104 og qua2saq, aqua: /ayruore ayyunge apie uonerepid O/g aendi uomes9ja2ap Ur 1u92S9p ON qu929p Jo aanyred - = 43 | up0idxo :Ld9 ON a ia | ars dT a1 19089p Jo way ae ween ace ay ge Ty Z< uoneie[:p Jo saare Arepuosag | | ay i< ue | aseyd uonessja20p paSuojoig | eee ora 1 | ae synug> | ayunr> 1uaasap parvenoig 3p wuz yuesedxg sy/wid¢"|> aYsuDg > uonewpp aseyd-aanse parsenoig a ora asau pag sypIe ayoz< Ssvyd quowy pafuojorg me O/d uoneSuo} dt ruaunessy EN uroned 1097 siloeg JOqeT euOUqY OOP PP HT 2018) Fides G, Mina (UPCM Compiled by Rosa, Abnormalities of Passage 1, Bony dystocia - I ‘AP diameter 2cm and not on the pelvi r ‘oration is a) 45° (LOA/ROA to OA, or LOP/ROP to OP) r_b) >45° tation is between 0 and +2cm Not currently recommended 1. Successful if a Accurate cup application at flexion point b. Appropriate traction que . Favorable flexed fetal cranial position d. Low station at time of application 2. Soft, bell-shaped vacuum recommended for uncomplicated OA position 3. Limit to 2-3 “pop-offs” for 15-30mins 4 PromptCsiffailed fein) Of a fetus through an abdominal incision (laparotomy), ff by uterine incision (hysterotomy) ee Indications to CS i (Fi (previa/abruptio) x a ; & end HN 7 Multiple Pos-term pregnancies Compiled by Roa Fides 6. Mina (URCM 2018)| | | distress 0 ee complications Nalpresentation IL Mtmctive lesions in lower genital tract Contraindications to Cs } status mpromised maternal st 1 Cons with trisomy 13/18 or known con, ienital death (anencephaly) anomaly that may lead to Techniques of CS 1. Laparotomy 2. Midline infraumbilical b. Vertical ¢. Transverse (Pfannenstiel, Mayland, Joel Cohen) dehiscence 2, Hysterotomy ae Classical — longitudinal cut above LUS, ae gi © LUS, not done due to high rupture b. Low Segment ~ preferred method i. Transverse (Monroe-Kerr) ~ less bladder dissection, but little extension; easier to repair ii, Vertical (Kronig, DeLee) ~ more bladder dissection but can be extended ~ Stronger, less Risk Type of CS Classical ‘T-shaped Single low transverse NVUWwwuww | Multiple low transverse Prior uterine rupture Lower 36% Upper 9-32% 1. Consent 7. Cephalic 2. No CPD 8. Small fetus 8. Active labor 9, Prior vaginal delivery |e. 4. Advanced cervical dilatation 10.Prior CS was low tans ¢, Experienced OB attendant single scar Double set-up in case of CS 46 Compiled by Rosa Fides G. Mina (UPCM 2018)Stages PROLIFERATIVE STAGE/FOLLICULAR PHASE : + Rising estrogen levels > proliferation of stromal & epithelial cells + Endometrial thickening of 2-3mm, ; BVs * Selection of dominant “ovulatory” follicle + Prolonged in anovulation * Surge of LH 2 days before ovulation “eet STAGE/ LUTEAL PHASE luces estrogen and progesterone Preparation for implantation and BY, + lipid and glycose™ fenia eweling & formation of tortuous glands : a. 4-6mm thick s by a “3 a 47 CConupited by Rowa Fides G. Mina (UPCM 2018)yENSTRUATION \d estrogen causes vaso: rogesterone an . spasm of BV and “2 on Jeading to desquamation initiates uterine se number represents Parabasal cells, middle number the int +1 2g number the superficial cells . les Fam10,90 ~ adequate marked estrogen effect $20/75/5 - poor estrogen effect ‘ermediate cells, 9100/0/0 - absence of estrogen like in postmenopause 2/100/0 - maximum progesterone effect (pregnancy) IMPERFORATE HYMEN MT amenorrhea (cryptomenorrhea) with cyclic, crampy pain starting at puberty * Hematocolpos > hematometra ~> hematosalphinx > endometriosis « Bulging membrane at introitus «Tx: hymenotomy TRANSVERSE VAGINAL. SEPTUM + Associated with intrauterine DES exposure * Bet upper 1/3 and lower 2/3 of vagina + Similar ssx as imperforate hymen + Tx: excision MULLERIAN FUSION ANOMALIES 1. Complete duplication, asymptomatic : 9. Non-communicating uterine horn: cyclic pelvic pains, pelvic mass, ectopic pregnancy : 8. Septate/Bicornuate uterus: reproductive wastage, uterine dysfunction, abnormal fetal presentationRegularity - cycle to] Absent | ~ ) cycle variation in 12| Regular | +2.20 days mo. (days) Irregular | >20 days | Prolonged] >8 Duration (days) | Normal | >45-8 Shortened] __<4.5 Heavy | >80 | Volume (mL) Normal | 5-80 Light <5 sural Bleeding (previously menorthagia) = excesive menstrual ae lity of life tring with quality of life lod sual bleeding (previously metrorshagia)~ occurs between clearly + Imermeyelic and predictable menses viiterm DUB isno longer used ‘Acute AUB - bleeding in a non-pregnant fertile woman with sufficient quantity immediate intervention to requir «Chronic AUB - AUB for past 6 mos. | NORMAL FACTORS FOR HEMOSTASIS Higher thromboxane level (PGF2) in relation to prostacyclin (PGEs) 2. Fibrin clot formaticn 8, Stabilization of hemostatic platelet plug POLYP, Endometrial + HMB, IMB, postmenopausal bleeding, dysmenorrhea + Dx: UTZ, hysteroscopic imaging + histopathology + See benign gynecological lesions section for more details ADENOMYOSIS *Growth of endometrial glands and stroma in the uterine myometrium at a depth of at least 2. a basalis layer of endometrium + Ginical painful prolonged HMB, corpus enlarged to I4 wks. : “exons ble ns for blee olncreased endowne endometrial surfa eared PCE/PGFs. balance 7 myometrial contractility Abnormal myometrial angiogenesis associated with fragile BV *Types "4S asymmetrically enlarged, no tenderness Solitary or multiple ee i ‘Compiled by Rosa Fides G, Mina (UPCM 2018)sal (close to cavity), intramural (in myometriy, oSubmucorrjace) parasitic Gndependent of uieray "vero ge tion + Classificn ce or absence Primary © PF submucosal (SM) or Others (0) ore ~~ submucous, intramural, subserous ° s for bleeding = Reasons Ty endometrial surface due to mechanical distortion etjceration and hemorrhage of endometrium overlying the submucous olmerference by myornas with normal uterine hemostasis o Mechanical compression of venous drainage by myomas at uny site Dilatation of venous plexuses draining endometrium « See benign gynecological lesions section for more details MALIGNANCY and HYPERPLASIA (see gynecological malignancy section) COAGULOPATHY «Von Willebrand disease «Chronic anticoagulant drug use (warfarin, heparin, low molecular weight ¥ > a i. = a 2 ‘Clinical: Unpredictable bleeding, variable amount of flow, HMB, nonsecretory endometrium «MC after menarche (immature HPO axis, (-) predictable cyclic progesterone production from CL) or just before menopause (decline of inhibin and rise in FSH > luteal out-of-phase events + Assoc with endocrinopathies ~ PCOS, hypothyroidism, hyper?RL, mental stress, obesity, anorexia, weight loss, extreme exercise ENDOMETRIAL + Predictable and cyclic, typical of ovulatory cycles, w/o other identified causes cae rv ees endometrial hemostasis regulation i € + IMB or prolonged bleeding ~ deficiencies in molecular mechanisms o endometrial repair IATROGENIC : bleeding, irregular bleedi ovulation + to meds that impact endssnesium, blood coagulation, contre of * Ex. OCPs, IUD, steroids, tranquilizers, digitalis, Dilantin, rifampicin. NOT YET CLASSIFIED * Chronic endometritis 50 ‘Compiled by Kosa Fides G. Mina (UPCM 018ane mara a high dose eu vo~ Rt nal - Tranexamic acid 1 g 3-4x/day PO during hea 3 Needing for 3 2 \e swells! Hormonal “i Tevonorgestrel-rel * XSmbined OCPs ¢. Cyclic togen: Medroxyprogesterone (Provera) 10mg po OD on days 15-26 4. Danazol 200-400mg PO OD oN hormonal — anti-fibrinolytic agents, NSAIDs +. ‘management of HMB } Suis" Dilatation and curettage — NOT RECOMMENDED etrial ablation ~ first line in non-desirous of cy and no structural/histological abnormality c. Hysterectomy — not first-line Tx days mnt of Chronic HMB easing intrauterine system once every 5 Primary “absence of menses in woman who has never menstruated by 16 ¥ yo. CLASSIFICATION of I” amenorrhea with NEG) | «Breast (2) means estrogen is being produced J Dverus (e) means ¥ chromosome is not present ‘A Breast development (-), uterus (+) 1. Gonadal failure - 45 XO (Turner syndrome), 46 X, abnormal X, Mosaicism, pure gonadal dysgenesis, 17 a-hydroxylase deficiency with 2. By ic failure 2° inadequate GnRH release ~ neurotransmitter | 3 eer Kallman syndrome, congenital CNS defect or neoplasm cn Pituitary failure east development (+), uterus (-) : Soleo (testicular ferninization) po cba absence of uterus (uterovaginal agenesis) 1. 17,20-desmolase 2. Agonadism 8 Wachydroxylase D. Breast deficiency with 46XY kary development (+), uterus (+) Dae 5 Compiled by Rosa Fides G. Mina (UPCM 2018)management of Acute HMB a Medical Hormonal - high dose estrogen, high dose co: ygestin 9. 'Non-hormonal - Tranexamic acid 1 bleeding for 3 days Medical management of Chronic HMB B. 1. Hormonal - a a. Levonorgestrel-releasing intrauterine systern once every § wy. mbined OCPs, 8 8-4x/day PO during heavy b, Gombined OCPs ¢. Cyclic progestogen: Medroxyprogeste PO OD on days 5-26 Pr osesterone Provera) 10mg 4. Danazol 200-400mg PO OD 9, Non-hormonal ~ anti-fibrinolytic agents, NSAIDs 3. Surgical management of HMB 2. Dilatation and curettage ~ NOT RECOMMENDED b. Endometrial ablation = first line in non-desirous of pregnancy and no structural/histological abnormality a c. Hysterectomy ~ not first-line Tx Primary + Absence of menses in woman who has never menstruated by 16 & yo. CLASSIFICATION of 1” amenorrhea with NEG + Breast (+) means estrogen is being produced + Uterus (+) means Y chromosome is not present g A. Breast development (-), uterus (+) 1. Gonadal failure - 45 XO (Turner syndrome), 46 X, abnormal X, Mosaicism, pure gonadal dysgenesis, 17 a-hydroxylase deficiency with defect, Kallman syndrome, congenital CNS defect or neoplasm 8. Pituitary failure B, Breast development (+), uterus (-) L. Androgen resistance (testicular feminization) - cx Congenital absence of uterus (uterovaginal agenesis) g 2. Hypothalamic failure 2° inadequate GnRH release ~ neurotransmitter development (-), uterus (-) LY { 1720-desmolase deficiency a a-hydroxylase deficiency with 46XY karyotype P. Breast development (+), uterus (+) 51 ‘Compiled by Rosa Fides G. Mina (UPCM 2018)3. Ovarian etiology ic etiology _ Hypothalamic etiol " : Pituitary etiology & Drerine etiology ry time period, usually longer than 6 syndrome ~ post-traumatic/post-curettage intrauterine adhesions or synechiae W/ oligomenorrhea/amenorthea & inferulty «Sheehan syndrome ~ postpartum pituitary necrosis + simmon syndrome ~ pituitary hemorrhage not related to pregnancy ‘see Table on nezt page of endometrial glands and stroma in an aberrant or heterotropic location outside uterus ETIOLOGY : 1. Retrograde menstruation 2. Coelomic metaplasia 3. Activation of embryonic nests 4. Lymphatic and vascular mets 5. Immunologic defect 6. Genetic predisposition 7. Iatrogenic Dissemination COMMON SITES 1. Ovaries (endometrioma/ chocolate cyst) 2. Pelvic peritoneum 8, Uterine ligaments 4. Sigmoid 5. Appendix 6. Pelvic nodes 7. Tubes pon AND SYMPTOMS nia), | Classic symptom ~ cyclic pelvic pain (2° dysmenorrhea/dyspareunia) », inferlity, abnormal bleeding + Classic sign ~ fixed retroverted uterus with scarring and tenderness. Posterior to the uterus; nodularity of the uterosacral ligaments a sac of n rectovaginal examination , 52 ‘Compiled by Rosa Fides G. Mina (UPCM 2018)Pscudomenop, use SEMENT MANAG Tal Tio create state of pseudopregnancy or 1. Mel Estrogen antagonist ~ Leuprolex b. GnRH agonists ¢. OCP ¥ 4. susieal - indicated for acute rupture of endometriomas, » Ureteral/bowel . SurBitcion, ovarian endometriomas, >2cm or adnenal ean Bements +8 Bem a. Laparoscopy b. Conservative — removal of all macrosco; preservation of ovaries 3 ¢. Definitive - TAHBSO if far-advanced and no desire for fun ure pic visible areas with fertility Ter rent ofurethra (urethrocoele), bladder neck, bladder Beis ise do ctpeire or atiemiatlon of the puboreliac hace oes & symptoms: sensation of fullness or pressure; feeling of organs fli Signs Fest incontinence; urgency, incomplete voiding; soft, bulging, non- a tender mass of anterior vaginal wall which may be manually reducible 3 URETHROCOELE & CYSTOCOELE « Diagnosis: patient in lithotomy position asked to strain ‘pbx: inflamed Skene’s glands (tender & purulent), urethral diverticula (sensation of a mass), bladder tumours +Tx: Non-operative: peccaries (Smith-Hodge or inflatable), Kegel exercises (sometric contractions of the pubococcygeus muscle), estrogen cream BD Operative: anterior wall repair (colporrhaphy) usually in conjunction with posterior wall repair RECTOCOELE + Heaviness or feeling of falling out in the vagina with constipation or incomplete emptying of rectal vault ‘Treatment oNon-operative: same as above SOpentve nesierioe wall repair (colporchaphy) with perineorraphy (or weakness of perineal body) ~ ENTEROCOELE 4 «Due to weakened support of pouch of Douglas utrosacra & rin 1s in post-abdominal or vaginal hysterectomy nation shows *Seen asa ‘bulge above rectocoele which on tans P small shadows in the sac “ (Moschovitz " «Treatment: reduced wansabominally asa primary proceduré a as Compiled by Rosa Fides mina (uPcM 2018)INE PROLAPSE ‘Due to injury to endopelvic fascia, ve devator abi muscles) « Due to 1 presstire/tension on pelvic musculature suc ue aon, tdmours, BA/ COPD, multiparity, co pathy, SI-S4 injuries) " «Classification ; asst degree ~ prolapse in upper barrel of vagina cardinal & uterosa cral ligaments and pelvic Le a i Second degree ~ prolapse thru vaginal barrel into introitus has in chron: Old age, sacral nerve d/o (om ‘Third degree - prolapse out through the introitus whi oFnyness & thickening of vaginal epithelium and stasis ich Dredisposes to Fourth degree - Providential: entire uterus as well as a vaginal walls extends outside the introitus at all times « Signs & symptoms: perineal heaviness or fullness or sensati: symptoms of cystocoele & rectocoele * interior and posterior ion of mass with = Non-operative: peccaries, estrogen © Operative: vaginal hysterectomy with anterior & posterior repair with a perineorrhaphy to reinforce introitus licturition ] [Parasympathetic (Ach) |Contraction > Micturition icter [Sympathetic (NE) ntraction > prevents micturitior RISK FACTORS 1. Immobility 9. Cognitive status oe eee i 10, History of fecal impaction oe 11. History of low fluid intake 5 rales 12, DM, Obesity |. Hi il ees ; i 7 ie weakness io Hypoestrogen state ot : 15, Racial status 8 2 Test for Bree cotane no sain 10-15 mins of *esidual urine should be stress incontinent & Urine spurts out after delay > detrusor insuabilen © + prethroscopy - visualization of urethra se ; ' 10 cough ity & Yroscopy & cystometry ~ best used for diagnosis of hyperactivity TYPES OF INCONTINENCE | Genuine stress incontinence * Urine loss due to sphincter incompetence without demonstrabl contraction of bladder detrusor muscles «Urine loss with increased intra-abdominal pressure (cou Uitteing, laughing, lifting) I pressure (coughing, « Loss of PUV angle (NV <120°) Table to stop stream when voiding ‘incontinence disappears during the night 9. Desrusor dyssynergia/ irritability instability involuntary contraction of the bladder during distention with urine or detrusor inability to stop their stream & nocturia + Urge incontinence ~ involuntary loss of urine associated with a sudden and strong urge to void + Detrusor hyperreflexia ~ if a neurologic disorder is present (stroke, Parkinson's) + Dx: electronic urethrocystometry + Tx bladder retraining, anticholinergic or B-adrenergic agonists (ropantheline, oxybutynin, imipramine, ephedrine) 3. True incontinence + Loss of urine without abnormal bladder function due to fistulas or other damage to the urinary tract 4. Overflow incontinence Neurologic disorder or partial obstruction of the urethra > inability 0 ‘empty (increase residual urine) > overdistended bladder > overflow other fluid a «Chronic with an urgency-frequency problem, painless urine loss, Infections of the Vulva ‘ ‘Infections of Bartholin’s glands, due to obstruction of ducts at 5&7 0clock $ration at the introitus, complicated by abscess formation . esas tquicntn tenes caused by pox virus i r-wart” .Condyloma acuminata (venereal warts) 56 ‘Compiled by Rosa Fides G. Mina (UPCM 2018)viral STD due to HPV 6 & 11 \ 5 ee Ox podophylline, TCA, 5-FU, Cautery Genital Ulcers ‘ee table on next page * « May include infection peed Agr ‘Endometrium — endometritis Soviducts - salpingitis cay os Uterine wall - myometritis © terine serosa and broad ligament ~ parametritis Pelvic peritoneum + Organisms oN gonorrhea oC. trachopmatis : Endogenous aerobic and anaerobic bacteria + Risk factors oTeenager Multiple sex partners W/o contraception DIAGNOSIS + Minimum criteria for empiric Tx 1. Lower abdominal tenderness a 2. Adnexal tenderness 3. Cervical motion tenderness + Additional criteria for diagnosing PID 1. Oral temperature >38.3°C 2. Abnormal cervical mucopurulent discharge or cervical friability a a. Presence of abundant numbers of WBC on saline microscopy of vaginal 4. Elevated erythrocyte sedimentation rate 5. Elevated CRP 6. Lab documentation of cervical infxn of N. gonorrhea, C. trachomatis econ ¥ endometritis ial bi ith his i e E eS romer aan ee i Hiesceath erin cs wi revo ee rae fluid or tubo-ovarian complex, or Doppler studies ee infection (tubal hyperemia) a 8. Laparoscopic findings consistent with PID nage by Ron Fes 6 Mina UPCH 019T ‘ Teaepan Atpedouspe | jemi ‘porensoj ‘ i eaavepq, esrepq A sepnosg | emddne‘apuoy, | TEENS | staat tia | sspusenet ing ldeouse te uounwosup | a1qene,, aapuar £19, wounuo5 rensnug, upeg unig i uu Ayeuorsse299 yos auon uur uoneinpuy fre ~Ayoaq, y8nox snorewisypAro quand pue poy SIGEHEA, na, ‘snoiag -uou ‘ooug —_ pareasyy daap 40 perysadng parearoxy Tepysedns =| doap so eoyradng deg Teao seman [rao senousy ‘passes | ier ‘pareastg | 30 punos‘pareaayg | ‘pouruuaipup, enna: paraiso ee pe arqeLeA, uM 01-3 unUI9Z-6 wg-| wnuIgT-¢ pug — aosaqeo Aeur 39saye0o suorsay STEEN ne nn ‘adnqnur Aqqensy | Aeus ‘ajdninyy t indeg = erent gq |*tmsndsoamndeg] —aporsoq aindeg SM 1 symg - skepz SEP F1-1 shep 2-6 f FIA FS a Beseanic, i ProasueyD sodzopy | smryd4s S2fn pees:Nats le dose + d Ati IM single dose + doxycycline 100; Mbeferiaxone 25078 PO BID I days ™B PO BID 14 days + Metronidazole ee obenecid Ig PO single dose + d ocefosti 3 igazole 300mg PO BID 14 days”? UN¢ 100mg PO Bip 4 ab 9g IV ql2hrs + doxycycline 100mg PO or IV qlhrs ° pr waitin 9g IV qéhrs + doxycycline 100mg PO or IV ql2hrs oCefox eadmit if nergency cannot be R/O 5 our arian abscess oPreenattiness, N&V, high fever erable to follow outpatient regimen to oral therapy oNo response ie Endocervicitis - N. gonorrhea, C. trachomatis Ectocervicitis - T. vaginalis : + Mucopurulent cervicitis 1. Purulent or mucopurulent endocervical exudate visible in canal or endocervical swab specimen 2. Sustained endocervcial bleeding 3. Leukorrhea >|0WBC/HPF in absence of signs 4. Gram stain: gram (-) intracellular diplococci MANAGEMENT 1. Azithromycin 1g PO single dose, or 2. Doxycycline 100mg PO BID 7 days C trachomatis — azithromycin, erythromycin PN. gonorrhea ~ ceftriaxone, cefixime . ; Vaginitis Normal vaginal discharge: white, floccular, odorless with pH 3.8-42 » DIAGNOSIS air * Criteria (8/4) or Nugent Criteria (2/4) for Bacterial Vaginosis: 2 pHoas vaginal discharge (thin, watery) . . smell when mixed w/ KOH ( (+) Whiff te80) 4) on wet 4 = carne epithelial ce'ls by being covered W/ 59 Compiled by Rosa Fides G, Mina (UPCM 3018)Nystatin 100,000U va, Metronidazole 2g PO ODT Or 500mg PO BID 7 days Tinidazol 2g PO OD OD Miconazole 100mg Boban y 14 days Metronidazole 500mg PO BID 7 days ididiasis/ Trichomonas Cardin Sieniliests vaginalis nerella a <4.5 35 G3 | 2° — Gard-like, floccular, |~ Thin, foamy, Homogenous, gray, Vaginal | viscous, adheres to | profuse, yellow- | rotten fish smelf seer discharge| anterior & lateral gray & foul- lading 10xKOH (Whiff vagina smelling teat) : Severe pruritus & Vagina, | burning sensation, an ormce] Minimal pruritus or cenit | redness, excoriation, | ore on cerviz | Vulvar involvement wall dysuria = et smear: = «| KOH smear: yeast flagellated, ovoid, Wet smear: Clue cells Diagnosis | ells & pseudohyphae a oe oeauae >20% Miconazole Metronidazole Metronidazole ae Nystatin Tinidazol Clindamycin Vulva + MC: Sebaceous and epidermal inclusion cyst * Others: Bartholin’s cyst. Apocrine cyst, Skene’s gland cyst + Cause: occlusion of ducts/hair follicle * Tx: incision & drainage, excision if EIC HEMANGIOMA {Malformation of BVs in childhood * Types 60 ‘Compiled by Rosa Fides G, Mina (UPCM 2018)—— Se subcutaneous nodules or deeper (71 oe or pressure Sx and acute pain “fe Bion WOLVODYNIN cle > chronic discomfort etch-sera! Yagina DIVERTICULUM URETHRA ss mass of anterior vaginal wall from posterior inneding o Appe . permanent epithelialized sac-like projection “ ea - Dysuria, Dyspareunia, Dribbling [Dx voiding cystourethrography, cystourethroscopy ‘nx Excision, marsupialization EPIDERMAL INCLUSION CYST ‘+ MC vaginal cyst + Appears as mass of posterior or lateral walls of lower 1/3 of vagina Cause: occlusion of pilosebaceous duct or blocked hair follic «Tx: I&D, Complete excision Cervix POLYP + MC cervical lesion + $Sx: IMB, post-coital spotting in multiparous women aged 40-50yo + PE: ectocervix ~ pedunculated, smooth, reddish-purple to cherry red, fragile + 5 x a 1 endocervix - grayish-white with short broad base a 2 2 + Tx polypectomy/excision (pedunculated) or electrocautery (sessile) + Causes: Congenital; infection, atrophy, or scarring from surgery or RT; obstruction with neoplasm, polyp or fibroid aia + Premenopausal SSx: dj smenorrhea, AUB, amenorrhea, infertility, é = ys 2 SSx: Asx > hematometra, hydrometra, pyometra * Tx: gentle dilatation with dilators or laminaria AOEMIAN CrsTs cervical cyst * Cause: Mucous retention cyst of endocervical columnar cells when clefts setted by squamous > Blocked a *Tx: None 61 ‘Compiled by Rosa Fides G. Mina (UPCM 2018)ae Uterus poLYP wth of endometrial glands and aire A stro: : + Benign oral hyperplasia 2" to unopposed estrogen” *Va8Cular core due 7 id rence: 40-50Y0, tamoxifen takers Sissx: IM 1B ., 4 SS M7, sonohysterogram, biopsy if>35yo + De: Jjyneroscopic resection if symptomatic \TOMETRA Taal with blood due to obstruction of any part of LCT. «Congenital: iniperforate hymen, transverse vaginal septum * Acquired: cervical stenosis, senile atrophy, synechiae LEIOMYOMA/ FIBROIDS < MC pelvic tumor ~ benign monoclonal proliferation of $M cells of myometrium + MC type: Intramural «+ Associated with HMB: Submucosal « Degeneration oHyaline ~ Most common, mildest oMyxomatous oFatty 1 oRed/carneous ~ during pregnancy Indications/ C/Is fomatic 8-6 mos. GnRH analogue, Depo-Provera, danazol. Mifepristone ZI Rapidly enlarging mass, persistent AUB, pain or pressure, enlargement of ASx to >8cm in women who wish to Preserve fertility CA: Pregnancy, advanced adnexal dse, malignancy, severe reduction of endometrial surfaceey Corpus luteum ‘Theca lutein | Failure of CLto | tence of dominant Thea pasa y follicle legress stimulation byhcc | ‘rranslucent, thin-walled,] | Smooth, red to Hypereactio luteinaliy 7 filled with clear, water to brown; gray-white (multiple cysts), if chronic joneycomb appearance ‘sraw-colored fluid ret smal Straw-colored fluid" | " irger, simple, TZ: Tx: TAHBSO since occurs post-menop: Enormous Multilocular with mucoid substance Transitional cell tumor Solid mass or nests of epithelial cells surrounding fibrous stroma Coffee bean nucleus Rare, small, smooth, Asx Tx: excision 7 a 3 ,TMC owgrowing ovarian tumor MC tumor in prepubertal femuie | All’ germ layers present, with ra I prominence/tubercle of Rokitansiy ee = 9 &| Benign Cystic | associated with: Thy : Thyrotoxi, i Teratoma | syndrome, autoimmune poss Carcinoid them to lie anterior and supe, ing ro Pepeciee a aewues™ | Chenin Sr varian tumor Extremely slow-growing and oni Whorled pattern on xs epee. | Meig’s syndrome: ovarian fibroma « | hydrothorax rote Tx: Excision Fibroma ie Benign vs Malignant Pelvic Masses ity — foe = [Mobility Consistency Cystic Solid Surface Smooth Irregular [Laterality — Unilateral Bilateral ; Prepubertal ie crea Reproductive: -| pcrmenopaisal age OCP taker s Ss SS Cystic ‘ No solid Muldeystic.— Consistency components _| Nodular, pape Calcifications _| Irregular walls . ww—= -al ey ignant changes in cervical epithelium usually in transf « pre-maligm yew squamocolumnar junctions > highest mation zon (bet old and te cervical GA Strate Of metaplasia) thar wh fae S18 = 18, 31, oHPV 16, 18 4 and E7 necessary to maintain mali Ty viral ‘and me chromosomal instability) ‘gnant phenotype (binds to g sexi nual activity > inc infection om jultiple sexual partners ercourse at early age olierescjgeconomic Status SGenetic predisposition — ; onoking - tobacco by-products in cervical mucus, weaker a rder to fight HPV infection ns immune system Alcohol - increased HPV infection 8 — highest oncogenic potential > these strains can Jess than 21 yo ; . i Atypia: increased N:C ratio, hyperchromasia, perinuclear halo, irregularity in nucleus, clumping of chromatin Intervention ‘Normal limits Routine screening _ [Inflammation w/o atypia “Treat inflammation [Inflammation w/ atypia “Treat inflammation, repeat pap Colposcopy & biopsy or repeat pap smear after 3 mos., HPV DNA testing | Colposcop Colposcopy + biopsy & Endocercival curettage manos cls oT uncertain significance (ASCUS) [Cannot exclede cOCPS for >Syrs | oDES exposure PAP SMEAR ~ Screening starts at 21 yo or $ years after onset of sexual activity not is ~ perinuclear cavitation & nuclear atypicality ‘CIN ~ mild tia S Cin |” Mild dysplasia, abnormal cells up to 1/8 of basal epithelium TEIN moderate dysplasia, abnormal cells up to 2/3 of basal epithelium ~ severe dysplasia, abnormal cells involving full thicknessjosaicism Mil Coarse | Icerations o 1 ‘Ablative Therapy: Cryotherapy, CO: cold-knife cone I «3 MC malignancy in female repro tract TYPES 's Squamous : MC, arising from ectocervix + AdenoCA: arising from endocervix + Others: Mixed (adenosquamous, glassy cell) CLINICAL FINDINGS + MC: vaginal bleeding (post-coital, IMB) . foul-smelling vaginal discharge $ ! cPE: ‘exophytic (cauliflower-like) or encoplivitc (barrel-shaped, adenoCA) DIAGNOSIS + By biopsy STAGING | I + CLINICALLY - mainstay of treatment is NOT surgery | + Tools that can be used: all “scopy” except laparoscopy (surgical) | ‘Proctosigmoidoscopy and cystoscopy to R/O bladder/bowel invasion | sGannoe use MRI, CT’, UTZ as part of staging since not all institutions have | em + Mets work-up: imaging, RFTs, LFTs, KUB-IVP, barium enema, CXR, skeletal ! survey (not bone scan) > for mgmt. purposes, will not change staging! be TREATMENT ! + Early stage: surgery (advantages: preserve ovaries, explore intraoperatively, ! s Preserve sexual function) or concurrent Eerenr cheat and radiotherapy (chemoradiation) with| Postmenopausal) xB cycles ; »A.10-20mg OD x 14 days Es desirous of uterine servation or if poor vurgical risk, same as menopausal. UTZ and sample endometrium after 3 normal - MPA 5mg x 10days/mo. x 12 mos. T pertieat = MPA 40-100mg OD x 3 mos, bi ff not, EHBSO of pregnancy: »A.10-20mg OD x Smos jegestrol acetate 40-200mg/day EHBSO + MC malignancy of genital tract + MC in perimenopausal and postmenopausal = MC Sx: AUB PATHOPHYSIOLOGY of + Chronic unopposed estrogen stimulation + Atypical complex hyperplasia precursor Decreases risk Pregnancy & lactation OCPs ‘Tubal ligation & hysterectomy w/ ovarian conservationgia —paic pressure, abdominal fullness & bloating, Marker: CATIS, Epis Mic presser thelial tumor, psamomma bodies; high grade; worse Serous rognosis; resembles FT Resembles endocervix/GIT_ Mucinous endocerving GIT Lendometrioid | Resembles endometrium, - a Hobnail cells (abundant glycogen) | Clear £c ——TResemble bladder transitional cells | Brennet T= MC ovarian CA in women < 80yo, pelvic pain due to rapid growth & hemor . MC malignant GCT (-seminoma) Dysgerminoma | Marker: LDH. Endodermal Schiller Duval bodies ~ numerous hyaline droplets Marker: AFP. Flemorrhagic, highly malignant cyto and syncytiotrophoblast ChorioCA Marker: hCG ‘Sex Cord- Strom: Gall Exner bodies ~ coffee bean nuclei in clusters around Granulosa — central cavity; estrogenic ane ‘Sx: precocious puberty, AUB, PMB Resemibles fetal testes; testosterogenic Sertoli - Leydig _| 55x: Masculinization, hirsutism VULVAR ATYPIA + Squamous cell hyperplasia ~steroids + Lichen sclerosus - Tx: testosterone cream, topical steroids + Intraepithelial neoplasia - RF: HPV 16&18, obesity, chronic HPN; MC SSx: itching, Tx: excision, vaporization Vulvar CA, Basal cell CA + Melanoma ‘VULVAR CA + MC squamous cell CA + MC in women >60yo + Spread: femoral-inguinal nodes a IMC Ssx Itching > deep pelvic, iliac & obturator + PE: raised, flat, ulcerated, plaque-like or polypoid masses on vulva + Tx: Wide radical vulvar excision and bilateral inguinal-femoral node dissection seevaging apie Vtitallntraepithelial Neoplasia and Cancer 68 ‘Compiled by Rosa Fides G. 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Mina (UPEM 2018) ‘Compiled by Rosa| grup oy puodag uorstuiaax9 199.1p 40/pue esoonuL [e994 10/pue sapperq sopeaur sown, | VAT ae “uD PavIO]je oq 03 9809 B HULIad 10U sap eUISpe snojiNa fuiNIDex 10 oppeg 242 Jo BsoINU axp paafoaut sey 10 stafed nun at puosaq papuarxa sey euOUTDTeD | AT i TRA atAjad 0 paptioixe sey eEuIOUTSIe> fem SiApod stp O7 paptoixo 10u sey Inq onsen [eUTeAgns poayoauT sey EUIOUIIIED, Trem Teuldea 07 par EWIOUD TED I ‘Yo weuide jo Huang ODT 600 uorseaut jo 1utod asadaap ap 0 eided jeutzop teoysadns asous 1uaoeipe 0 uxt jewrons jeyayntda Woy sow Jo JusUIDANseIUT Se PoUYap UoIseautt Jo AGI. Ni2upd Surpnpursewauesip Auy] gAl ang Ni [esourej-oumsuy pares3[n 10 poxy YO ‘attog atajad 01 paxty Jo “esoonut e194 ‘esoonuy Jappeyq ‘esoonur feurea s0/pue pexpom soddn 2 atp Jo Aure sapeaut sour L, samANs | aueasip 40 (eumea soddn g/g ‘estpam soddn g/g) feuorBoz Jatno sapeaut sour]. peaids zemsdesenxo tim sspou aanisod (+) (wmuIg>) SISUT NT &< HO (GNU $2) IOUT NT B= EM 2018) Fides G. Mina (UPCM i ‘Compiled by Rosa,$-0 DODT-Adesstporpey "B-0 NODA ‘Adesoypoursy) ‘6-0 DODA *Aiawng ‘suopepusUTWIOITY nox ABoj02U0 peorFojo22U45 = 909 1028 posqnz/OHM 241 VV ‘dnos8 A¥ojo9uo aanresodoon wisreg = peod | 0 c Sie yjav ou Tpo|GESTp AppIa|duIOD, an . DouEIs|sse [eideds specu ‘sinoy Funfem: Jo XOG sTeYD 40 paq O2 P2UTJUOD ‘91e9-Jf9S OF PITT ov-08 g =imoy Hupjem Jo YO Peg Jo ang "JuoM 01 ajqeun ‘azeo-s[a8 Jo ayqedeo mq AzoreInquty 09-09 t Tatanoe snonuaas uF pauses ing Aroveinqury: 08-02 t stay paensesun ‘aanse A no 001-06 0 [par ARDY sI095 VOU —“SOS7 jaIODg SNIEIS STUCULLUOF IO -sonbruypar Susseunt 1ua.2ytp £q pauriojsad st uauussasse asuodsas ou wHoyM ur siuaned ose pue satase pue suotso] ansAo papnpput seasip a]qemmsesuiUON “ZN 9 WIlOg> “fo west 1) £q WUIO|> SULNseaUL SuoISD| Se POULDP Sf aseaSIp a[qEINSEDLLTUON “UALOGS) resco fajdea3ouose nit Aq 40 (WUTC) Ueos 9 Aq s8a88e JOUIM PHOS Se POUL Sf ISERSIP SuOIa| MU Jo UORUDGRUDpY sao) wins SuNfaseq Ut XOG Jo asKOIOUT| ” suOISD] a]quinseaUE UT Xz JO asta.DU! | so aeasp sigeerau fe jo isurmp, so we gAUapt 10 2A0qe PAqEDP Se Y Su101s3] MAU Jo WiattropaAapI | sup om asvasip ajqeanseau [pe Jo siaurerp| L asaBuoj wins aurjaseq UE XOF JO astaID: X9G> JO aSLAIDUT 40 XOS> JO padi suotsa] Mau Jo auido|anay Anoypus .aseastp a[qesnseaur [fe jo s19.9Ure asa UO] UINS DUTIasEG UE KOE JO 28K: [asea] we Sunsey suosa} 214) Ig ‘SUOTsoy SsEasIp 2quANsED ye Jo siaiourerp jo lonpoud uy SUOISo] MoU 07m UD aauapina ie Jo vORINIoRes 2194 o aauapiea je Jo uonn ay ek uNe Uy SMS LST GAO) MPO {3019 ust Ee aerate enorrhea after final nstruacion, 12 Mos, 0 d tion of Me permanent CESS ‘i PP perma peri use: 47-48 yrs, age genetically determined and estes of Filipino Teno Por ovullations, race, socioeconomic status I + eana§ ATED to number © puysiOLOcy inhibin production + increase in pituitary FSH + no change f " in progesterone : . i decrease FO irregular ovulation > failure of progesterone . , Depletion ot sy ceases Slack of estrogen > atrophic ovaries ll DUCED ESTROCEN eae EFFECTS Or pathognomonic sign jety, depression, fatigue, headache, decreased dysuria, nocturia [Bone [Tae atrophic vaginitis, uterine prolapse, cystocoele, rectocoele, | incontinence, frequen: ‘TREATMENT 1. Estrogen replacement therapy ~ Bisphosphonates (Alendronate-Fosamax), SERMs (Raloxifene, Tamoxifen) 2. Ca** 1500mg/day and Vit D 1500mg/day 8. Weight-bearing exercises Productive-age couples to achieve pregnancy after 12 mos. of a frequent (weekly) intercourse 4 curring with one cycle of FEMALE Facto midcycle intercourse, NV: 20%7 alformation ot genital malformat Submucosal fibroids Uterine polyps Operative hysteroscopy Uterine “Asherman’s syndrome Luteal phase defect, Cervical stenosis Surgical or mechanical Cervicitis dilatation, IVF Cervical Unfavorable mucus d |______+——_ Endometriosis Remove surgically MALE FACTORS Gauses MCMT {Etiology _———¢ryptorchidism Abnormal Mumps orchitis semen Anti-sperm antibodies Hypogonadotropic Endocrine ada hMG i Radiation Environment Heat = Kiinefelter's syndrome oan Immobile cilia syndrome eat Erectile dysfunction Ejaculation failure IUI, intra cytoplasmic tenon Retrograde ejaculation : mae sal Varicocele Artificial insem of donor defects Vasectomy | sperm if refractory Testicular torsion DIAGNOSIS | OVULATION DOCUMENTATION | + History = + Midluteal progesterone level (>10n : $10ng/mL) Basal body temperature (midcycle elevation) + Endocrine evaluation + Endometrial biopsy (abn: proliferative chan 5 n ges only) cme reserve ~ clomiphene citrate challenge test in >35yo (if FSH on 8 day > 212 mlU/mL > impending ovarian failure) 9 felvic ultrasound ~ uterine structural defects coeERMANALYSIS ~ 2-8 specimens within 2-#hrs collected after 22-8 days is 76 ‘Compiled by Rosa Fides G. Mina (UPCM 2018)the patient ‘ te ng Medisina. Andito ako Jeet po ae Pde Mina, oe at poctan. Maari po bang wma Pe asaminasyon ng MYONE Cs 5 z pore ae rane patient used vaginal suppositories douche, or had intercourse 3 Check iti ga-48 hours i itory sa ° in the past 0rpo be Raye 2 nakipagtalik, gumamit ng suppository sa pwerta, feminine wash?” oe patient to void ‘na po ba kayo?” ie by the patient for the exans ae ‘Humiga nap o sa kama, itupi ang mga oa long pe sen Tusog po ninyo ang pwet malapit sa gilid ng ita, at ipatong ang mga bent 56 He i tin ng tela ang pribadong parte ng heme. Habang ineeksamin kop 0 kayo ay tatakipan natin ng tela ang. atawan ninyo.” see po a matilie at mapapagusapan natin sa eksaminasyon ay mananatiling ‘Sabihin niyo lang po kung hindi na kayo komportable. 6. Wash hands and wear ciean gloves. Prepare materials t Twill need the exam table with stirrups, flexible light source, drape, gloves, tissues, sanitary pads, speculum, lubricating jelly, glass slide and cotton swabs for the pap smear ecam. For our setting, we use water instead of lubricating jelly.” “The patient is draped to maintain her privacy.” prior to the examination. 1 Inspection of outer genitalia a Pubic Hair b. Swelling © Lesions d. Masses me glnfestations end har ditriation 4s normal/abnormal. There is/There is no swelling, lesions, 2 a eee labia and clitoris sna ~ size (normal/enlarged/atrophied) b trophied) o Clitoris ~ clitoral ‘mutilation, clitoromegaly, redness, swelling, lesions, labia are normal in size/e ; : “rece, ne ing otk There is/There is no clitoral mutilation 7 papeing withthe hile/clorles/ purulent, with thn/thick consistency, mo Lene to ang lab ng puerta ‘May masakit po ba?™ Compe by Ro Pde Gin (UPC 300amass ete on te palpation of the labia and clitoris, neni THE Fret and prolapse of the urethra.” 4 Ieee rede mee P pret i THE of glands ‘ ‘inspector ch tateral superior aspect of the introitus. Pal $ gland re ee milking the undersurface ofthe retions by for abnormal Sr yaginal wall using your index and middle glands are glands by placing Yo thu the fi of your index finger palm-down in the vaginal orifice, palpaing the Yland gently between your thumb and finger at the 7 nd Piand 5 o'clock positions ‘ SS paper metinns went amen eS /without swelling, 4 Inspection of introitus Discharge : b. Hymenal ring (virginal/nulliparous/multiparous) there it no discharge, swe redness and lesions. The hymenal ring is ginal/nulld Compit 79 ‘by Rosa Fides G, Mina (UPCM 2018)Te gownward pressure on ‘Apply he vagina. Y ro relax the ineroreculum at a 45 dee + iMgle and open blades fully angle and J hasbeen identified. eS vagina a oth/parous or with raggae/nuliparous, with pale/pinkish The vag snucosa. There are/There are no lesions seen.” Inspect cervix and os. a Color b. Position cc. Smoothness 4d Discharge : 3 ~The cerviz is pink/red, round, openiclosed/patulent, directed anteriorly/j : smooth/rough, with/without discharge.” (posteriorly, 7. Use Aylesbury spatula to collect ectocervix specimen and endocervical brush to collect endocervical specimen. 8. Properly apply swabs to previously labelled glass slide. 9. Fix slide 10. Inform patient that speculum will be removed 11 Unlock ‘speculum and slowly withdraw speculum while slowly closing es. 1. Insert fingers proper! 2. Palpate vagina ‘vagina is smooth and multi 2 4. Palpee carvan tera Parone “The cerviz measure ae tenderness” UM” 222 om, it is round, open/closed, firm/hard, with no cervical motion Bimarwal Examination Palj egintTus and take note of:¢. Mobility a pas reer nigel 10 AOG, symmetricaVasymmetrical, anteverted/retroverted, ith nodules.” c. Masse’ onpalpable (ideally: small, almond shape, around 2-8cm). There aretare no adnexal masses or tenderness. ~ ‘Rectovaginal Exam: 1 inform patient tothisstep E eee eee ‘pong malalim at ey ag nee 2 Slowly insert middle examination finger into the rectum with the index finger in the vaginal canal 8. Assess uterosacral ligaments and parametria, rectovaginal septum. 4. Check for tenderness or masses in the cul-de-sac and parametria. ‘a. Normal: smooth and pliable eS Cervical ee to the side wall, nodular ‘The patient i tone, intact rectal vault, intact vaginal septum, no intraluminal masses, smooth and pliable parametria, bulgir cul de ie a bulging/full cul de sac, and no bloodites sew 4 6S oO Ee tere CSF eset accent be SOK) Sanne 5 jotherapy cr- external bear Fa ae ERT re equal bray rece carer ual rly reacre 1 HEN gh al ches: expansion Be Srimated feral weight FEN accive laparotomy EUrz early wrasound F F-female BBD - full body bath daily BS - fasting blood sugar FDU- fetal death in utero EP - full equal pulses FeSO4 - ferrous sulfate FH fundic beight FHT/FHR- fetal heart tones/fetal heart rate FMC- fecomaternal complications FMCQID - fetal movement count four times day FT full term, ; ae eo Besta a See ae inked immunosorbent ass TE internal examination {for rectal exam) i 1PM - intrapartam mor voy on weigh large or genatona age LLO - left lower quadrant Le fo ast menstrual periodast normal menstrual peri TRDR - labor room & delivery room. SCS - low segment cesarean section {SIL- low grade squamous intraepithelial lesions LTCS - low transverse cesarean LUQ - left upper quadrant LUTZ - late ultrasound M M-male M-2- murmur Mag Sul - magnesium sulfare MV-- multivitamins N ABS - normoactive bowel sounds NAMT - no adenxal masses or tenderness NAWG - not around when called NEG - normal external genitalia NIL- not in labor NPSP - non-promiscuous sexual partner NRRR- normal rate & regular rhythm NST - non-stress test NVE - neck vein engorgement ° 02 Sat - 02 saturation ‘OBAS - OB admitting section OF! - oral fluid intake OGTT - oral glucose tolerance test ONG - ovarian new OPD - out-patient department ~ operating sponge (ito yung sterile gauze!) =‘TC - to come back ‘TD - thyroid disorders TH- total hysterectomy THBSO - total hysterectomy with bilateral 4 i A y 33 \ 3 Jboplastin time aay ni mr HL 4 i t aa u U/A (with stat alb) - urinalysis (with albumin testing done immediately) Urine CS - urine culture & sensitivity USO - unilateral salpi UTZ - ultrasound 38 v ‘VBAG - vaginal birth after cesarean section \VDRL/RPR - venereal disease research lab/rapid plasma reagin phi BIO)] >1.0t0<15 0 ae 0h ee Red Top ~ Blood type, electrolytes Purple Top (2ec) - Blue Top 0. Ro eres Coombs ore HbAIC (invert 8-10 times)BT cBC a U/A Save blood | 0 cBC | 5 iA‘ satalb Pr/PIT, AST, ALT, BUN, Crea, LDH, Na, K, Cl, Ca, Mg, Alb, RBS 94-hr urine: TV, TP, Crea (with simultaneous serum BUN and Crea) Save blood o¢ a 0 UA Urine GSCS Endocervical swab GScs Rectovaginal swab Gscs 900000 o O Save blood ‘equested with the residents, oo o Bich 090000 oo000000 o USUAL LABS REQUESTED BT CBC U/A 8-HCG. Save blood BT CBC U/A PI/PTT, 12-L ECG AST, ALT, BUN, Crea, LDH, Na, K, Save blood CXR 2D echo BT CBC U/A PT/PTT CXR PA 12-L ECG BUN, Crea, Na, K, Cl, Mg, RBS Save blood BT CBC 0 U/A+ stat ketone BUN, Crea, Na, K, Cl, RBS i O Sar TRO! BT CBC U/A AST, ALT, BUN, Crea, LDH, Na, K, Cl, Mg, Ca, Alb, Alk Phos, RBS oO FT4,TSH 0 8-HCG (diluted) O Save blood oO Oo 12-L ECC. CXR PA ooo 8 a These are just the USUAL labs requested; always confirm the diagnostics to be Compiled 84 by Rosa Fides G, Mina (UPCM 2018)OF COMMON DIA‘ tO Lal 125.00 | ALT 240.00| BUN 45.00 | Crea {95.00/unit |_LDH {250.00 | Na 75.00 | _K 150,00 | CI 70.00 | Ca 735.00 |_Mg 7,000.00 | Alb “HDAIC 450.00 | _RBS e-HCG diluted 785.00 | 12L ECG #-HCG undiluted 465.00 | _CXRPA (CXR PAL LAB VALUES (from Williams Obstetrics 24% ed.) ‘Nonpibgnant Ist TT Er ls USS aL ung References ‘Ail nairetic peptide Not epoted Nol reported 28.-70.1 Not reported n mew 2d —-22*1S yen TA i coat iy So 7-83 25-75, 1101 4,22 i nase MB (y < Not reported Not reported | 18-24 a NI-pro-BNP (pg/ml) S0#26 60445. 60 40 BL A Troponin (9/7!) (+008 Not reported Not reported wn 119-349 8 18,31,42 oe 4887 8, 18,31,.2,55 O13, 101-24 8, 18, 31, 42,55 os 2136 31 Mi win hae TS} 818, 31,38,0,55 TH) 45-262 18,33, oe 85 ‘by Kosa Fides G. Mina (PCM 2018)Tr] fiorecad rT Pioeeitad 233 PST] 5,39, 42, 70 26-45 2342 3,5, 26, 29,39, 42, 72 17-88 25-126 38-229 3, 5, 39, 42,70 ngs IN 327-487 a us 130-400 ~130-590 398 ee = 273416 3A 24-83 1673 15-81 32, 39, 42, 68 wT 12416 216 2 33 33 432 5,39, 42, 70 20-24 20-24 20-24 a 0rd = 01-08 O14 5,39 Ors Odd 0-05 5,42 01 O01 oot 5 49 091 ons 5,14 22268 S116 8-4BB 3A, 30A, 67A Gum, ionized (mg/d) 45-53 45514450 4453 26, 42, 48, 56 Gum, total (mg/dl) «87-102 8B106 = 829.0 8297 3, 29, 39, 42, 48, 56, 63 Cenuloplasmin (73/41) 2563 30-49 4053 4-78 42, 44 Chloride (mé/t) 102-109 101-105. 97-109 97-109 20, 39, 42, Geatinine (ng/¢!) 050% = 00708 04-09 39,42, 45 Gamma-glutamy! 9-58 2B +n 46 5, 42, 39, 20 transpeptidase (661) + wy a dehydrogenase = W522) 733 BONA 82-524 42, 29, 39, 70 pase (U/L) 43 2-76 26-100 4h ‘Magnesium (mg/dl) 15-23 1622 1522 es 3, 26, 29, Ae 42, 48, 63 “al (mosm/tg USI95 75280276289 278-280 1.8 Phosphate (mg/d) 25-43 3146 A546 Potassum (méq/) We) seep aha ae 38 3A Prealbumin (mg/d) 14 15-27 20-27 very DDS REE Protein, total (9/1) 6745 6278 S79 : Sodium (réq/) ° So6? 26, 29, 42 THM 134812148 fel Day ee s 1320-14817, 26, 29, 39, 42, 63, 66 Potergah a ra +13 +1 20, 39, a2 249 363 1 : 86 ‘Compiled by Rosa Fides G. Mina (UPCM 2018)Er] Trimester 2nd foe Le? References ce : eee ee os 612-1170 = 595-945 vs170 197-182 131166 1 ae wags eee Shas rei BIO <” 15 +8 +2 27,61 <7! (520369 0542 6 s190 DSHS so-166 22, 66 amis 0h116 SS 102114 61 wr 3 1038 135 6 <1 eta ares 4635 a torr SS ars 17,65 ae eae ot 3006. Hardy Obes SBE Mit STB treme Canines Corset Se retment Gusdenes Pelvic FOGS. 304. Clinical Practice oe a nastory disease ee Sa Gal en Caen en lr negra, Fock port Giseal Pracice Gudelines on Obseare Heng een POCE aold Cliscal Practice Guidelines on Aborink, e™2rThage FORE 2044 GlakalPracice Cudeline or Arora Fock bois Cam Praice Cudlines on Foe gous (aie Pracice Cuséehines on Uhscr ant ony Preemancy Score i Ga Pace Cacon on Prac apee ™ We Oaie Practie Gadehon, Compl 87 Sy Mow Fiies . btina (UPC 2018