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Maternal Fetal Physiology

Benign Anemia Of Pregnancy; There is normally a 38% increase in maternal blood volume. This
will raise in 30 weeks. Note that plasma volume increases by 47% and this relative dilutional
effect lowers hb but will cause no changes in the MCV

Incorrect;
Folate deficiency; leads to a macrocytic anemia
IDA: will cause a microcytic anemia

Physiologic Dyspnea of Pregnancy

THis will be present in up to 75% of women, this is not consistent with a PE, which will manifest
with hypoxia, chest pain and signs of a DVT. There wil also be fatigue, SOB, palpatations.

Increased Minute Ventilation; note that an increased minute ventilation will caue a
compensated metabolic alkalosis. This leads to increased PC02, and the P02, will be decreased.
This is consistent with a viral URI.

Respiratory Function in Pregnancy;

Result of PFTs are consistant with normal pregnancy. Note that inspiratory capacity increases
by 15% during the third trimester. While the RR does not change, the tidal volume is increased
leading to alkalosis in pregnancy.

Pulmonary Edema;
For these patients, they have pulm edema and need Lasix, there will be increased plasma
osmolarity which causes an increased susceptibility in pulm edema. SVR is decreased

Pylonephritis;
- While increased progesterone will cause changes in in the smooth muscle dilatation, the
uterus will rise and it will cause compression at the pelvic brim. This will cause uretral
dilatation. This can cause raised RBF and decreased serum creatinine.

Right uterine compression; this will cause dilation in the ureters and the renal pelvis. Note that
the right ureter vein complex which is dilated in pregnancy may contribute to right uterine
dilation.

Thyroid Hormone Levels;

TBG; this will increase circulating estrogens, while free T4 is normal, T3 levels will increase in
pregnancy.
- Note that there will be fatigue, other changes are anemia, difficulty sleeping and raised
metabolic demand.
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Glycosuria; this is not diagnostic of DM in pregnancy, however, this will be diagnosed by

abnormal glucose testing. This will cause impaired tubular resorptive capacity for filtered
glucose. A contaminated specimen will be supported by leukocyte esterase on dipstick

IOM; guidelines,
Underweight (< 18.5) should gain 28-40
Normal: 18.5-24/9 (25-35 lbs)
Overweight (15-25)
Obese: 11-20 lbs

Preconception Care;

Sickle Cell Anemia; this will be an AR disease that will target 1/500 black births. The carrier
state or the sickle cell trait is found approximately in 1/10 black patients, each time 2 carriers
conceive, there is a 1/4th chance of developing disease.

Diagnosis of SCD; Hb electrophoresis and CBC will be used to diagnose SCD. This will have alpha
and beta thalassaemia. Although SCD will he diagnosed , we can detec. Note that a smear is not
useful for carriers.

Pregnancy and Asthma;

- The effects of pregnancy on the curse of asthma are variable. This will worsen during
pregnancy. Avoiding triggers is extremely mportant. Lack of transportation is also a risk.
Note that severe and poorly controlled asthma is associated with increased risk for
cesarian delivery, morbidity and mortality.

CF; this is associated with Ashkenazi Jewish folks, the carrier risk is approximately 1/25, because
the patients husband is not Ashkenazi or French Canadian, there is a little risk for Tay-Sachs.

Valproic Acid; note that this is at an increased risk for NTDs,

Cardiac Abnormalities; Women with poorly controlled DM prior to conception have a 408 fold
risk of having a structural anomaly.

Obesity and Pregnancy; Note that the patient is obese, this will be a risk factor for DM, HTN,
high cholesterol, stroke, heart disease and certain types of cancer and arthritis.
- Note the bullt community, lphysical and social characteristics, healthy food and
designated walking areas are key.
- We need to provide opportunities for health weight goals.

Cell Free DNA; All of the tests for trisomy 21, and 18, this will have
- First trimester test; this will have nuchal translucency,
- Triple screen; second trimester AFP, B-HCG,
- Quad screen (second trimester triple screen + inhibin A, 81%
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Fragile X; this is the most common cause of inherited ID, this will occur in about 1/3600 males

Folate Supplimentation; This has been shown to decrease incidence of NTDs on women with
antiseizure meds, this is a definite risk to pregnancy. Valproic acid is associated with with
congenital malformations. Most common are NTDs, ASDs , cleft palate, hypospadias and
polydactly.

Spontaneous Abortion
Note that the patient has classic signs of uterine perforation.
- This will cause scant vaginal discharge, complications are second to D&C are anesthesia
risk, bowel and bladder injury

Causes for Spontaneous abortion

Genetic abnormalities; this will cause by chromosomal abnormalities
Infections are only 15%
- Most common, is going to be an autosomal trisomy

DM: this along with chronic renal disease and lupus show a raised risk for early pregnancy loss.
This will be increased with poor metabolic control. Other risk factors; genetics, endocrine, and
reproductive tract anomalities.

Smoking
Along with caffeine and alcohol consumption, this will be associated with miscarriage.

Active Bleeding;
Because the patient is actively bleeding and is haemodynamically unstable. Need to perform
D&C. Misoprostol only if hemodynamically stable.

Expectant Loss; this can be managed with explusion of contents and surgical evacuation (give
about 8 weeks for management). Regardless, need to type and administer rhoGAM

Cervical ceriage; this will be placed at 14 weeks. Thiswill reduce risk of miscarriage

Recurrent Pregnancy Loss; will test for anticoagulant, anticardiolipin and DM/thyroid disease
testing is done as wel.

Medical Management Benefits; 800 mcgwill be administered to women to confer a shorter

time to lead to fetal exit.

Hypertension in pregnancy
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RDS: Recall, excessive MgSO$ can cause decreased respiratory function, the classic signs are
decreased DTRs, nausea and RDS, if the magnesium is in high doses, we can even see cardiac
arrest

Management; Regardless of delivery status; the only definitive therapy for preeclampsia is
delivery of the placenta; the delivery is delayed in a setting of stable disease; Hydralzine,
labetolol and nifedipine can be used

Complications of Hypermagnesemia;
Note that with a level of 11 mEqL, RDS is most likely to occur. The therapeutic index is 4-7.
Cardiac toxicity will occur at 15 MeQ

Thrombocytopaenia; This will be below <100000, this is a contraindication to expectant

management. Others include nonreassuring fetal surveillance, eclampsia, persistent CNS
symptoms and oliguria.

HELLP Syndrome; this is a process of preeclampspia; this will indicate hemolysis, elevated liver
enzymes and low platelet. Leads to increased swelling of the liver capsule and possibly liver
rupture.

ALF of pregnancy; later term, malaise, anorexia, n/v, epigastric pain

Placental Abruption; this will accompany the tachysystole; this will show fetal anemia
*tachycardia and sinusoidal heart rate pattern.
Bloody show; less intense with bright red or brown blood
Vasa previa; placenta previa or low lying placenta.

Preeclampsia; with BP > 140/90 and and creatinine is 1.2

Low dose aspirin; beginning with 16 weeks and continuing will reduce risk for recurrent
preeclampsia.

Antepartum Care;
Because the patients GA based off the last LMP and the PE findings are discordant, the most
reliable exam methods are a dating US, quant H-CG will not predict GA, US should be done
between 14 and 15 6/7 if there is >7 days between ED and deliverty. This will approximate EDC

Cell Free DNA screening; this is the most effective screen there is for down syndrome, the test
may be performed as early as 9 weeks gestation until delivery. Quad screen will look for AFP,
estriol, HCG and inhibin A

Glucose tolerance screen (three hour that was abnormal), management will teach about the
diabetic diet and how to monitor blood glucose levels. This will be havig the main goal of
assessing and maintaining blood sugars.
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Ultrasonic Assessment of the fetus; in addition to fetal weight, AFI can yield additional helpful
information for management; this includes shoulder dystocia, metabolic disturbances,
preeclalmspia.

Adverse events/occurances; this will be an adverse event or occurance; an incorrect was given
to patient. These findings will go directly to QI and risk management.

Neural Tube Defects; this is associated 1-2% incidence of NTDs specifically lumbar
meningomyelocele. This will be occurring within 16-18 weeks gestation. Leads to spina bifuda,
cardiac defects and facial clefts.

MSAFP; this will be assessed after with fetal demise, multiple gestation, ventral wall defects.

Amniocentesis; this will detect DS as well as other chromosomal abnormalities.

NT; this is the fluid collection at the back of the fetal neck in

Wafarin; THis medication is contraindicated in this gestational age, ibuprofen is safe until 32
weeks gestation. Note that warfarin has obvious teratogenic effects. Give Plavix instead

Excessive Gestational weight and birth weight IOM has revised guidelines on the pre-
pregnancy masses. Must discuss appropriate wiehgt gain, diet and exercise at the initial visit.
Should limit weight gain to 0.4-0.6 lbs a week

Intrapartum Care
Overview; this will be Braxton Hicks Contractions; there will be a soft, nonacute abdomen,
general surgery consultation is not indicated. This will be a soft, non acute abdomen, in which a
surgery consult is not indicated.
- GDM will be diagnosed based off glucose challenge tests.
These contractions are short and less intense than true labour with discomfort in the lower
abdomen.

Group B strep culture; Cultures for GBS are not required for those who have group B strep
bacteria during the current pregnancy or who have previously given birth with early onset GBS,
- These will receive intrapartum ab in labour

Retained Placenta;
This patient demonstrates a prolonged third stage of labor with retained placenta. She does not
have a post partum hemorrhage with EBL of 350 ccs, her second stage of labour has already
been completed.

Fetal Scalp electrode;

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If the FHR cannot be confirmed externally, the most reliable result is to use a FSE, placing an
epidural without confirming fetal status maynot be dangerous. While an US may provide
information, it is not practical

VBAC;
If the patient cannot deliver; the next best thing to do is assess fetal station and look at an
emergent forceps or VACC. None of the other options will provide a expeditied delivery

IUPAC: note that if the Intrauterine pressure catheter is placed and there is a significant amount
of vaginal beedling, the possibility of placental separation should be considered Note that this is
the most appropriate strategy.

Uterine Cord Prolapse; although the fetal surveillance is reassuring, the most appropriate will e
to elevate the fetal head with a hand in the vagina and call for assistance to perform a
caesarean delivery

Historically; the purpose of doing the episiotomy will be to facilitate completion of the second
stage of labor. This will improve both maternal and neonatal outcomes.
- Current data does not demonstrate any benefit.
- Avoiding use of episiotomy is the single best wau to minimize damage to the perineum

IUPAC: this will e used to assess strength of contractions,

Placement of a fetal scalp electrode is not indicated at this time, without determining
contraction adequacy, it is premature to perform a cesarian section. Oxytocin augmentation is
indicated if the patient is protracted

Late decelerations; these are associated with uteroplacental insufficiency, this will cause a rapid
change in the cervical dilation. Head decompression is linked to early decelerations.

Immediate Newborn Care

Down Syndrome; this will have a flattened nasal bridge, small size and a small rotated cup
shaped ears. This is associated with down syndrome, also we must look for sandle gap toes,
hypotonia, protrudin tounge and alpebral fissures.

Low Blood Sugars;

Small babies are most commonly associated with T1DM than with GDM, the blood sugars in all
newborns should be monitored closely after elivery and are at an increased risk for
hypoglycemia.
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CHorioamnitis; this will be in response to maternal fever, this is a sign that the patient is septic,
they can look pale, lethargic and have a highr temperature.

TTS: (Twin twin transfusion; polycythemia is the common complication for the plethoric twin
(TTTS) this is a complication of monochorionic diamniotic twins), there will become anemic,
polycythemic and will show IUGR and polyhydramnios. This can manifest with HF and hydrops

GDM Infants:
Infants born to mothers with DM have a higher risk of polycythemia, hyperbilirubinemia,
hypocalcemia, and RDS.

PPV/Intubation; recall that with any substance abuse (this may be a contraindication to
naloxone as the mother may have used narcotics during the pregnancy

AZT: This will occur immediately after delivery. HIV will begin q24 hours and there is no reason
to isolate infant even though mother is PPD positive

Circumcision; this is associated with a number of potential medical benefits; including penile
surgery, inflammation, dermatosis.

Following skin delivery of the mother, this can have skin to skin contact immediately. This will
involve clearing airway, bysuctioning the mouth. Delee should be avoided
-delayed stores are great and have a favourable effect on developmental outcomes.

Postpartum Care:
Sheehan Syndrome; this is a rare occurance; note that when a patient experiences a severe
blood loss, there will be AP hypoperfusion and ischemic necrosism this leads to TSH and
adrenocorticotrophic hormone, hyperprolactinemia

Prolonged Labour;
Note endometritis in the post partum period, most closely related to mode of delivery—this will
be occurring in less than 3% for vaginal birthds, there will be prolonged labour, prolonged
rupture of membrane and low SES status

Endometritis;
The differential here is UTI< lower genital tract infection, wound infections, pulmonary
infections and vaginal delivery
Risk factors; PROM, multiple vaginal exams and internal fetal monitoring, manual removal of
the placenta.
Pathogenesis; this will be caused by staphylococcus and streptococcus

Postpartum depression; this will begin 2 weeks to 6 months post delivery, this will be self
limited
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AMbilvalence; toward newborn; this will be with ambvilance towards the newborn, anhedonia,
crying spells and sleeplessness may occur

Post partum Atrophic Vaginitis;

This will be common in those who rbeast feed, they will show lower levels of estrogen in the
vagina which makes the tissue thin and more abraded.

Milk Supression; the safest method to halt lactation is ice packs and analgesics.

Breast Feeding; this is associated with a decreased risk of ovarian cancer

- There will be a decreased incidence of breast cancer, the breast feeding has not been
shown to increase risk for t2DM. Breast feeding is a major source of IgA

Estrogen Progesterone Contraceptives; especially in the first 30 days post partum, raise risk of
thromboembolic disease and diminish lactation.

Breastfeeding
Infant Positioning During Breast Feeding
Although the side lying position is a good one for breast feeding; belly to bely is key for the
infant to be in a good position. Mother should be counseled in a more comfortable position

Mastitis; this is caused by staphylococcal bacteria in the child south; note that mastitis is
treated with anti-staphylococcal antibiotics. If the infection persists an abscess can develop.

Policies Promiting Breast feeding; this includes baby getting to breast within a half hour of
delivery and rooming for the baby.

Delivery and Hoormones;

With delivery; there is a rapid and profound drop in progesterone and estrogen, this will lead to
increased lactose synthase and increased milk production

Candida; this is going to be associated with sharp discomfort and pain; this will be treated with
clotrimazole or miconazole creame, staphylococcus will have nipple features

IUD; this is the best choice because it is long term and it is reversible, it does NOT affect milk
production, I may have negative effect on milk production.

Evaluation that baby is getting enough;

This will be 304 stools in 24 hours.

Breast Discomfort;
The engorgement commonly occurs when mil comes in, the strategies for this include taking a
warm shower, and using warm compress to enhance milk flow.
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Oxytocin; this is responsible for milk production; there will be ejection of milk.

Direct Observation; this will reveal any maternal or neonatal issues that can allow for better
positioning.

Ectopic pregnancy;
Risk fators for ectopic pregnancy are going to be elevated B-HCg, this will be ultimately
confirmed by obtaining a B-HCg within 48 hours; there will be a fetal pole. The treatment is
with methotrexate. There is a stable patient and we need to confirm the diagnosies

Cesarian scar ectopic pregnancy; over 90% is in the fallopian tube. This will be in 1/2000
pregnancies. There will be implantation or migration
- Both increta and accrete are morbidly adherent

Viable intrauterine pregnancy; there will be an intrauterine pregnancy with elevated BHCg.
There will be within normal range.

Abnormal Pregnancy; note that the pregnancy is abnormal given the B -jg ;eve;s/

Ectopic Pregnancy;
Diagnsis with fetal pole and there is a B-HCg level over the discriminatory zone. There will be a
IUP seen on US.

Management of ectopic pregnancy; medical management is with methotrexate therapy. This

will treat the ectopic pregnancy and it will be less than or qual to 3.5 cm.

Ruptured ectopic pregnancy (hypovolemia, shock). Management is with laproscopic surgery

Rutpured ectopic pregnancy; this will be managed with salpingectomy because our patient does
not want additional children. Salpingostomy will be for wanting children.

B-HCg this is the most important test, it will show us if we have an ectopic pregnancy.

APGO:
A womans risk for development of ovarian cancer is associated with once ina lifetime. Note
that oral contraceptives can cause anovulation..

Functional Ovarian Cysts; this is often asymptomatic adnexal mass or can become symptomatic
this will be a uniocular cysts,
Incorrect; endometrioma; this is an isolated
Serous cystadenomas; larger than functional cysts and there can be increased abdominal
growth
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Dermoid tumours; this will have solid tumours that are ecogenic and can have teeth, cartilage
bone and hair

Omenectomy; this is going to be used to evaluate for ovarian metastasis.

Granulosa cell tumour; this will explain finding of the endometrial hyperplasia; this will secrete
high levels of estrogen that can cause hyperplastic changes.
- This is most common in the women in their 50s.

Germ cells; this will manifest in younger women age 10-30, epithelial tumours are overall the
most common and manifest in all ages. Krukenberg tumor this is from a primary site.

Ovarian torsion; this will be with an enlarged ovary; these are going to have a dermoid cyst as
the lead point and can ceate instability in the infundibulopelvic agent.

Ovarian Cancer Prognosis; the 5 year old survival with epithelial tumor is correlating with stage.
This will have been optimally debulked.

Ovarian Malignancy; the presense of solid components, lack of ascites and no mural nodules
indicates that it is benign

Germ cell tumours; in the women < 30, over 30 will be epithelial cell tumour

Asymptomatic cyst; this can be present in 20% of postmenopausal women, note that other
markers are normal note that these cysts are never drained as they can risk seeding.

Ovarian cancer screening; this is because the available screening options are not useful to
elucidate a pre disease state. When the disease progresses, mortality is higher.

Endometrial Carcinoma;

1. Endometrial Cancer; this is a gynecological malignancy that has easily indentifiable risk
factors and presents with symptoms leading to early diagnosis;

Risk factors; this includes nulliparity, late menopause, HTN, and exposure to unopposed
estrogens especially when the patient exceeds 50 lobs increase. There will be other risk factors
such as nulliparity, obesity, however the greatest risk for endometrial cancer is CAH.

Routine Health Maintainance; 80-90% of those with endometrial cancer will have vaginal
bleeding/discharge as their only presenting symptom. There will be late menopause,
unopposed estrogen therapy, nulliparty, obesity and tamoxifen.
- Others are HNPCC or lynch II
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Endometrial cancer; this will present with symptoms and clinical findings leading to an early
diagnosis. Most common finding is abnormal postmenopausal bleeding. There will be increased
uterine size as it grows.

Management of biopsy confirmed endometrial cancer; we need to do a hysterectomy with BSO,

there will also be staging to elucidate invasion and grade of the tumor.

Even if premenopausal; will do total hysterectomyy BSO and pelvic and paraaortic
lymphadenoectomy.

Granulosa cell tumour; this is an adnexal mass in the perimenopausal woman. This will have a
harbringer for a neoplastic process. This will show irregular bleeding and a finding of
hyperplasia.

Management in setting of tamoxifen therapy; note that tamoxifen I known to cause

endometrial changes. –biopsy is not a screening method.

Management of Vaginal atrophy; most common cause for vaginal bleeding is atrophy. This can
be managed with estrogen creame.

Management with Endometrial cancer;

This will be scheduled with gyn onc to determine staging or debulking. This requires surgical
staging this involves removing, uterus, cervix, adnexa and pelvic/paraaortic nodes.

Leiomyoma;
Most common indication for hysterectomy
1. Prevalence
2. Symptoms and PE
3. Diagnosis
4. Management

Benign responsile tumours; increased with estrogen---with menopausel there is atrophy and
growth cessation

2. Asympomatic mostly, but can cause heavy AUB, there is distortion of endometrial
cavity. Intramural can distort if there is size and quantity, subserosal is elast likely.
3. Increased pelvic pressure/size; this is a large myometous uterus; there can be large
menses.

Diagnosis; dependant on size, if there is a large fibroid, palpate uterinel week size, 20 week size
or fingerlength size. Then we can do imaging studies. Sonohystogram will show a nondistorted
cavity.
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Management; there is no treatment for small or asymptomatic fibroids. OCP can be

used( contraindicated with HTN, smoke and migraines), progestins and prostaglandin inhibitors
and GnRH agonists. (temporizing measure)
Treatment; uterine a embolization; who wish to retain uteri, myomectomy can be done
(abdominally or laparotomy), or submucosal fibroid.
Hysterectomy; this is definitive for fibroid (vaginally or abdominally).

Questions;
Fibroids; the major session associated with fibroids is heavy menstrual bleeding.
- There will be an increase in the uterine cavity size that leads to sloughing and an
obstructive effect that leads to ectasia and proximal congetion in the myometrium and
the endometrium; other symptoms include pain and pressure. This will cause pressing
against the bladder, bowel and the pelvic floor. Other symptoms are made at the time
of the routine pelvic examination.

Uterine fibroids; these are the most common solid pelvic tumours in women, on post mortem,
we can detect about 80% of fibroids; note that fibroids are associated with myomectomy.
- This should be avoided.

Leiomyoma; this is an infrequent cause for miscarriage and subfertility. This is with mechanical
obstruction/distortion; this can lead to recurrent miscarriage.

Weight gain; this is often due to dietary intake and absence of exercise; while she has a 4 cm
fibroid; it will not explain weight gain; she needs to quit smoking and practice healthy habits.

Endometrial Malignancy vs Fibroids;

1st we must rule out underlying endometrial malignancy with endometrial sampling; most of
the patients with uterine fibroids do not require surgical treatment; the endometrial cavity
needs to be sampled to rule out endometrial hyperplasia/cancer
- This will be most important in the late reproductive years
- GNRH analogues will inhibit estrogen secretion.

Medical Management for fibroids;

Conservative treatment; NSAIDS and OCPs, this next choice will be GnRH agonists. This is going
to aim to reduce symptoms, it will shrink 30-65% percent post 6 months with GnRH agonist.
While she is anaemic,;

Abrupt discontinuation of therapy; Maximal response is achieved with 3 months of GnRH

agonist treatment; this will also correlate with estradiol and body weight---although they
should not persist for longer than 1 to 2 months.

Uterine Fibroid Diagnosis;

The patients H&P is typical for a perimenopausal woman with uterine fibroids; this can be
considered with postmenopausal woman with bleding, pelvic pain---endometrial hyperplasia
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Adenomyosis; will cause symmetrically enlarged boggy uterus;

Fibroids and Infertility;

Note that gnRH agonists are critical for infertility work up; the next best step for management is
always GnRH agonists.

Work up for fibroids;

Despite the patient being asymptomatic, must prompt further evaluation to pelvic and adnexal
pathology ---endometrial biopsy is not indicated at this point.

Cervical Cancer;
Pathogenesis/Risk
Guidelines
Initial Management with abnormal PAP
Symptoms and findings

Pathogenesis; 16, 18, 41, 45—Low risk 6,11 are genital warts
Note it is at the SCJ; this is a key landmark for lower genital tract cancers; endovervical side
(columnar), squamous; ;durng menarche this will cause changes to drive SCJ forward and it can
recede with menopause. This will form a transformation zone. Will form squamous metaplasia

- Actc acid will cause white appearing wel and will show cells undergoing metaplasia;

Risk factors; immunocompromised, smoking (3.5xrisk), increased

Screening; Pap test q 3 years (no screening)

Pap q5 years; 30-65
65> can stop

Risk factors for screening, minority status, low income groups. Low access

Cytology; LSIL, HSIL; colposcopy will have histological diagnosis

CIN1, CIN2 (2/3 epithelium, CIN3 (full thickness)

Can test CIN 2 and CIN 3 with p16; perform colposcopy if needed. Immediate treatment
CIN1 and CIN 3.
Treatment; Can do ablation, cone or LEEP. Note ablation has no diagnostic information,
Cone and LEEP excise transformation zone; dysplastic cell is not excised.

Clinical presentation watery discharge and bleeding, it is irregular and friable

Prevention; Gardasil; low risk strain protection and 16, 18 prevention—91% infection.

Risk factors for Cervical Cancer

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Greatest risks for cervical cancer are HPV exposure and include early onset of sexual activity;
multiple sexual partners and HPV or other diseases; genital warts in particular indicates HPV
infection

ASCUS; repeat testing or cytology at 12 months post abnormal pap. The routine screening can
be resumed in q3years.

Cervical Cancer; risk factors include tobacco use and a poor screening history; this should be
taken seriously and a cervical biopsy must be performed; there will also be accompanied
uterine fixation and thickening of the rectovaginal septu

Neoangiogenesis;
This will include hairpin shapes and larger vessels there is a greater degree of angiogenesis; this
will not have undergone squamous metaplasia. Thiis is less concerning than above vascular
changes.

Unsatisfactory Colposcopy Management;

Because the entire lesion cannot be visualised, the colposocoy cannot be used, the conization
should be done to attain a pathological specimen.

Pathogenesis of HPV; this is a necessary event for cervical neoplasia, this includes dysplasia and
cancer; this will include smoking and immunological factors; such as development of cervical
cancer at at least 15 years from seperaton;
- This is not genitcally inherited.

Histology of Cervical Cancer; this is graded based off the involvement of the epithelial layer but
it does not extend beyond the basement membrane. Microinvasive below 3 cm.

ACOG screening guidelines; screening should begin at age 21 and those age 21-29 need a pap
test every 3 years. Ages 30-65 need pap test every 3 or hpv cotest with pap every 5 years. And
those post 65 can stop have they had negative pap smears q3 times or 2 negative co tests.

Why are the requirements changed; this will be for cost effectiveness.

Pap test discontinuation; should continue to have pap tests until she has 10 years of normal
results. They can disctonue if they have had 3 negative cytology tests and two negative co tests.
Must also NOT have high grade disease or cancer.

Vaginal and Vulvar Cancer;

The most crucial step is to first biopsy lesion; do not just treat lichen sclerosis with
glucocorticoids. DIphenhdyramine is also not appropriate.
- Biopsy is done to make a definitive diagnosis. It is also inapprorpriate to do vulvectomy
and lymph node dissection.
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Management; because the cancer is moderately differentiated; we will perform vulvectomy and
we can also do a groin node dissection---this is also inapprorpriate to laser a section.
Cryotherapy is not an acceptable treatment for vulvar cancer.. there will also have squamous
cell cancer.

Lichen sclerosis; the skin will be thin, inelastic and have crinckled paper.
Verrucous carcinoma, cauliflower like lesions
Melanoma; pigmented lesion. This can repreent mass as it will be assymetric and pigmented.

Bartholin Gland Cyst; this will require excision/biopsy, note that this arises from the Bartholin
gland. This is unlikely to be a fibroma or lipoma.
 40 or more, get a biopsy

VINIII: this will be treated with wide local excision; this will remove all gross disease---it is
inapprorpriate to do radical surgery such as cancer---treatment with TCA and imiquimod is
done for condyloma.

HPV related infection; condyloma or vulvar dysplasia, those who are currently on
immunosuppressive therapy are at high risk; note that these may be dysplastic. But they are
not the sole treatment.

Because the patient has vulvar HSIL, laser treatment is the best choice, without definitive
diagnosis, a vulvectomy is not indicated.
- Smoking cessation is also strongly encouraged.

Pagets Disease of the vulva; because this is an in situ carcinoma----the association of breast
cancer is significant there will be less association with cancer; unlike

Risk factor for vulvar cancer;

HPV exposure, including lower genital tract dysplasia and cervical cancer, smoking, vulvar
dystrophy and immunocompromised states such as HIV exposue, non smoker, alcohol is not a
risk factor

Gestational Trophoblastic Disease;

1/1500-2000 pregnancies amongt Caucasians in the US. There is a much higher incidence
amongst Asian women (1/800), molar pregnancy, this commonly occurs frequently in women
less than 20. This is higher in areas where folks consume reduce db -carotene and folic acid.

Complete Mole;
Will show multiple hydropic vili with cystic masses in the placenta; considered to be swiss
cheese placenta, this will occur in 95% of molar pregnancies. This will also show an abnormally
elevated B-Hcg.
- There can be other findings;
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Pelvic US; note that there is a discrepancy between dates and uterine size, a pelvic US will
exclude multiple gestation, uterine anomalies and a multiple gestation---quantitive B0HCG wil
be enough to visualise sonographically.
US with B-HCG can identify mole

Management for Molar Pregnancies;

Suction CUrretage; this is the standard management for molar pregnancies; note that we will
induce delivery with oxytocin.
- Methotrexate for post molar GTD
Suction curratage is not completely curative; therefore GTD can be managed with complete
evacuation. Additionally, this will have elevated B-HCG>

Complete Molar Pregnancy;

Although suction curettage of the uterus is indicated; we must rule out problems before going
to OR. Abdominal or brain MRI not indicated at this point

Choriocarcinoma
Note that this diagnosis is made once the presense of B-HcG is confirmed, this should have
returned to 0. Howeber with unclear origin, we must still use B-HCG.

Pregnancy Rule Out;

Note that before initiating other treatments; must role out B-HCT. Since there is a 20% risk of
preogession, we should continue to follow HCG levels till they are 0. Need to give effective
contraception to prevent development of a neoplasm.

Molar Pregnancy;
THis will show higher levels of B-HCG, this can form lutean cysts. This will also lead to higher risk
of preeclampsia with elevated BP

Molar pregnancy;
While US will perform and confirm molar pregnancy; hydropic villi is pathnomonc. It will
supress TSH

PMDD; this is going to be a series of symptoms if its cyclic or constant. Often these will be
mistakenly attributed to their periods.

PMS; this will have symptoms that warrant treatment; PMS and PMDD experience adverse
physical, psychological and behavioural symptoms during luteal phase. PMS will have somatc
symptoms. This will be PMDD, there are daily functioning and personal relationships.

Hypothyroidism; this will be consistently in the cycle. This will be used to rule out medical
illness. This will be used to work out medical causes. Elevated prolactin will not be associated
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with regular menses. PMDD, this is in the luteal phase, it is associated with psychological
symptoms that can affect usual functioning and personal relationships.

Bilateral oophorectomy; this is a last resort for women with PMDD, this will be refractory to
other treatments; however it results in early menopause leading to hot flashes, early bone loss
and CVD.

PMS/PMDD: this will have a menstrual calender for cyclic nature of PMS and PMDD. It is key to
establish diagnosis.

PMDD; the SSRI will increase active serotonin in the brain and is effective in relieveing PMDD.
Patients can take the medical every day or only one during the luteal phase.

Exercise; this will increase the amount of circulating endorphins or feel good hormones. This
will also decrease PMS symptoms

PMS/PMDD risk factors; Risk factors for PMS, obesity, poor diet, PMS is increasingly common
as women age through their 30s and their symptoms are worsened through tiem.

Normal Premenstrula Changes; this includes cramping, bloating and mastalgia. This will affect
2/8 percent of women, there will be debilitating mood symptoms that manifest in daily life.
Medications such as serotonergic and hormornes are for symptoms that impair functioning

Mangesium; shown to benefit pregnancy

Infertility
Reassurance and Observation; this is most appropriate as these folks have been trying to
conceive for three months. Note that after 1 month 20 % will conceieve, 75% after 12 months.
And after 12 months, 90% will conceive.

PID: this will cause adhesions and blockage of the tubes that can best be assessed with a
hysterosalpingograml this will have difficulty conceiving after one year.
- Hysteroscopy; will have issues assing uterine cavity.

PCOS: recall Rotterdamn Criterion;

Quitpiapine; note that this drug can be used to have antiDA effects. Note that this supresses
ovulation.

Exercise Induced Hypothalamic Amenorrhea;

This will show normal FSH and low estrogen; she may be treated with FSH and LH to help her
conceive

AMF levels; this is excellent as it will help us elucidate he ovarian resere.

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Fertility; note that women are most fertile in the middle of their ovulation cycle (28 days). They
are most likely to ovulat eon day 14; sperm live three days, note that intercourse three days
before ovulation still cause pregnancy.

Primary infertility; no conception for one year the main factor is female, but we should check
males first.

PCOS: Ovarian induction agents; first line management for ovulatory dysfunctionl this is based
off history/symptom. No reason for semen assessment at this time.

Hypothyoidism; this can cause yperprolactinemia;

Menopause;

Vaginal Bleeding; note that endometrial cancer; this is going to be manifested with AUB. Note
that a histopathological diagnosis is required beforehand.

Calcium Absorption; note that this will fall with age, a posivie calcium balance; this will require
1200 mg of calcium.

Osteoporosis treatment;
Risk factors; this will have fractures as a adult, low birth weight and being a current smoker
- A FRAX score can be caculcated and a therapy can be initiated for a 10 year risk score.
- BMD must be documented, and then we can start bisphosphonates.
- Other management strategies, calcium, vitamin D and avoidance of heavy alcohol
- HRT is not recommended

ACOG: HRt; this is the most effective treatment for severe menopausal symptoms including hot
flashes, night sweats and dryness.
- There should be counseling on the risks and benefits before initiating treatment. ACOG
specifically remmends that we administer the smallest dose of estrogen as needed

Expectant Management; this is recommended as she has minimal menopausal symptoms, there
is occaisional hot flashes. If her symptoms, use the OCPS for the shortest amount of time.

Hot flashes; management with short dose estrogen. The hot flashes will resolve completely in
90% of folks.

Estrogen production post menopause;

While estrogen production by the ovaries does NOT continue post menopause, there will still
be increased androgen production and this Is converted by fat cells to estrone. Therefore, with
surgery, the estrone will be reduced.
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Breast Cancer with HRT;

Note initiation of menopausal symptoms, this will be a safe option, this can be fore those withn
10 years of menopause or younger than age 60. This is usually going to have no
contraindications (CHD, breast cancer, prior DVT or stroke
- This is not seen inn women, the risk of endometrial cancer with unopposed estrogen is
not seen

Cholesterol Levels;
HDL increases and LDL decreases, both have confirmed the overall positive effects of HRT on
serum lipid profiles. Most important effects are reduction in LDL.
- Lipoprotein receptors will reduce LDL.

Evaluation for Fracture

FRAX can be calculated, there is a score of >20 % or major osteoporotic fracture this will have
family history, white or Asian race, dementia, history of falls, low body mass index, estrogen
deficiency and insufficient physical activity.

Dysmenorrhea;
THis is also considered painful menstrual cramps. These are often incapacitating.
- Note that the Cu IUD will increase the heaviness of the periods

Progestin; this will cause endometrial atrophy; note this is produced in the endometrium, it will
have SHBG. It can increase prolactin levels.

Chlamydia screening;
USPSTF; this recommends chlamydia and gonorrhea for sexually active patients age 25 or
younger. Note this can be a potential cause for symptoms.

Pap smar will be done at age 21

Laparascopy for medical resistant treatment;

Laparoscope; this will confirm the diagnosis of endometriosis. Other causes of STI and
PID/ovarian cysts
- SSRI; this is indicated for PMS.

Hysterectomy; this is seen in nearly 80% it will be effective in eliminating pain if the patient is
deciding against more children.

Secondary Dysmenorrhea
This will be menstrual pain caused by another condition----this will hav normal examination.
- There will be restricted uterine movement.
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AUB with leiomyomata;

Despite the patient having menstrual bleeding, we can use a biopsy to rule out endometrial
cancer.

Fibroids; this will have well circumscribed non-encapsulated myometrium. This will have
hyperplastic growth of glands/stroma.
Adenomyosois; this will have invasion into the uterine cavity.

Endometrial Polyp; this will occur between ages 45-50

- This will have increased menstrual flow. This will also show cramping and raised
menstrual flow.

Dysmenorrhea
First line therapy; this will be ibuprofen. OCP, is contraindicated for the patient has had a past
history of a DVT.
Endometriosis; this is diagnoised with lap and removed

LEEP procedure;
This will have invasive cervical dysplasia; cold knife, must remove it.. LEEP procedure this will be
more involves. The rate of regression is much lower , ASCUS

Complications; infection, bleeding, cervical stenosis persistent disease and preterm birth.

Endometrial Biopsy; this will be an office procedure that will not cause extreme patient
discomfort, note that it will be critical to tailor to patient care. This should be done
withhysterectomy or ablation.; hyperplasia can be treated with medical therapy or least
invasive procedure.

Vulvar Biopsy; this is unresponsive to treatment; the biopsy can ensure diagnosis. If the
diagnosis is unsure, a biopsy should be done.

Hysteroscopy; Hysteroscopy; operating room, IUD, fallen

Needle Biopsy; note that needle aspiration for a breast mass allows for pathological dissection;
minimal discomfort, this will not be reduced with changes in caffeine intake

IUD; note that the patients IUD is unknown, it can still be in the uterus, it can be expelled or it
can be intraabdominal. Note that she has just restarted her periods. It is concerning that the
IUD was expelled. Therefore it will be visible on US.

Breast Biopsy;
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Age and gender; this is the greatest risk for developing breast cancer; BRCA1, BRCA2, this is
low percentage of the general population

Foliculitis; this will have issues with shaving the axillary hair, note that this will have
appearance of eczema and it will ause a firm axillary area.

Prolactin; this stimulation will give rise to elevated prolactin. However it should be repeated to
rule out tumour. Note that there may be production of prolactin with breast feeding.

Fibrocystic changes; this is the most common type of benign change during the reproductive
years. The pain from this can be reduced with lower caffeine intake.

Breast Cnacer; the first noticeable symptom is a lump that feels hard next to breast tissue, it
can be detected by PCP or the patient themselves. Notably, if there is aspirate we have to
culture it.

Lactational Mastitis; most often occurs during breast feeding, the management will be to
continue breast feeding use cold compresses and providing ibuprofen

Malignant Breast Mass; this will be associated with FNA, however in situtations where the
mass persist, an excisional biopsy should be done.

Breast MRI: used as a screening test for breast cancer; with mammography, BRCA, Li fraumani
or women with chest radiation are at higher risk.

Chronic Pelvic Pain

1. Diagnostic Laparoscopies; this is the indication for 40% of all gynecological
lapraoscopies. In chronic pain, we should not defer laparascpic management. It can be
diagnostic and therapeutic for thisw who we suggest endometritis
2. IC: Interstitial Cystitis; this is a chronic inflammatory condition of the bladder with
recurrent irritative voiding symptoms; this will have unknown etiology.
3. IBS; this is a common functional bowel disorder with an unknown etiology; there will be
a chronic relapsing abdominal/pelvic pain with bowel dysfunction---note this is more
common in women with chronic pelvic pain, there will be 12 months abdominal
discomfort, relief with defectation, and onset with change in frequency of stool.
4. Sexual Abuse and Chronic Pain; this will have a significant association of
physical/sexual abuse with various chronic pain disorders, this wll be found in 40-50% of
women. , note that may cause biophysical changes.
5. Endometriosis; with adhesions and no desire to have children; bilateral
salpingoopherectomy.
6. Pelvic Adhesive Disease; this is a result of the prior hysterectomy and a post operative
pelvic infection; note that while she had PID; it is unlikely to be caused by this.
- Ovarian remnant syndrome; post ovarian surgical remova; can have pain still from
remaining ovary.
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7. Nerve entrapment syndrome; this is caused by misdiagnosed neuropathy via a low

transverse incision (T12-L1 and the ilioinguinal (T12-L1,) note these will pierce the 12 th
vertebral body and pass through psoas. Ilioinguinal will provide sensation to groin,
pubis, and the skin overling the pubis.

Obturator; inability to adduct the thigh

Indication for successful hysterectomy; if confined to the uterus, this is the most indicative for
success.

Fibromyalgia; this is constant pain refractory to hormonal manipulation. Note, we need to avoid
narcotics, GABAergic medication such as pregabalin and gabapentin should be considered
helpful adjuncts.

How to detect abuse; state regulated pharmacies will elucidate number of prescriptions filled
and who wrote them. While there criminal records will symbolize prior abuse, most places have
no record of prior arrest. They will often do doctor shopping.

Notes on Chronic Pelvic Pain

Non cyclic pain > 6 months, located to pelvic, inferior abdominal wall and lumbosacral region. It
is higher than migrane and asthma.
Etiology; non-gynecologic and gynecologic (endometriosis, malignancy, retention, adhesion,
PID, mesothelioma, cervical stenosis, adenomyosis. PID is the largest cause. This is due to
adhesive disease, chronic inflammation

Non-gyn; IBS, and interstitial cystitis;

IBS; will have marked bowel habit changes for 6 months, interstitial cystis; pelvic pain,
frequency dyspareunia.

Evaluation; the successful evaluation; caring physican needed. Recall there is a

- Carnett sign; abdominal pain, must do psychiatric evaluation, anesthesia
- Known

Medica; ovulation suppression---GnRH agonist

Surgical; hysterectomy done after non gyn causes have been ruled out

Endometriosis;
This is a typical symptoms including dysmenorrhea, dyspareunia and there is nodularity along
the back of the ruterus. There is also endometritis; this will be infection of the endometrium
Vagimus; this is involuntary spasm of the vaginal musculature. This can cause sexual pain.
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Cervical Stenosis; this is a result of prior cervical surgery; will cause retrograde menstrual flow
this can cause endometriosis;

Endometriosis; posterior cul de sac; this is along the uterosacral ligaments, this will cause
tenderness in the posterior fornix and posterior aspect of the uterus.

Endometriosis; surgery is the gold standard of endometriosis; it is not the initial treatment the
the surgery; this is often managed medical; the role of surgery is endometriosis; this is
especially pelvic pain----in the young nulliparious patient.

OCPS; this will be the next best choice for the patient, this will provide negative feedback with
the HPA axis, this will stimulate endometrial tissue outside of the cavity (uterus, endometriosis
and is with combined OCPS).

Danozol; will cause increased weight gain, increased body hair/acne---

Diagnostic Laparoscopy;
Definitive diagnosis; exploratory surgery/biopsies---laparoscopy, will have NSAIDS/OCPS

Endometrioma; this will be with history and US findings; there will be painful, asymptomatic
and found incidentally. Ovarian cancer needs to be ruled out. Mature teratoma, will have
calcification on US.

Endometriosis; this will have benefit with GnRH agonist; this will also allow her to respond.

Endometriosis; this will be used to diagnose and treat the tubal occlusion, this will
decreasefertility and ablation amy improve chance of conception. OCPS will not be indicated for
those trying to conceive.

Endometriosis; this may cause pain can also be asymptomatic; there is no further treatment.
This is going to include endometrial glands/stroma outside of the uterus.
Pathogenesis; there are three theories
1. Retrograde flow.
2. Colomeic Metaplasia
3. Lymph

Can cause adhesions ad scarring.

There are found in vilateral ovaries; endometrioma (brown hemosiderin fluid0, uterosacral
ligmant, round ligament and the sigmoid colon, can be found in brain, lungs and upper ureters

Apparence; brown power born or dark domes.

There is association with infertility; asymptomatic infertility
Dyschezia and rectal bleeding
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There an be no signs, can have no palpable; fixed retroflexed uterus, endometriomas and
uterosacral nodularity; Diagnosis OR;; tissue biopsy
Can see endometrial glands stroma and macrophages
- Minimize intervention preserve fertility

Treatment OCP; will cause atrophy and progesterone therapy suppress endometriosis, GnRH
will induce menopausal state
Danazol; will block LH/FSH can cause menopausal state and androgenic properties.
(virulization)
Surgeyr; excision, caterization, ablation and lysis
Hysterectomy with bilateral salpingoopherectomy

Pregnancy Termination

Septic Abortion; note that the patient has fever, and there is bleeding. Note that there is also a
dilated finding associated with septic abortion.

Missed abortions; retention of the pregnancy for a long duration despite no FHR.
Anembyonic pregnancy; gestational sac, no embryo

Septic Abortion Management;

This will include broad spectrum ab and evacuation on laparoscopy.
Methotrexate; ectopics
Misoprostol; for hemodynamically stable folks

Medical Abortion Risk factors;

Note that medical abortion associated with higher blood loss than surgical.
- No effects on future fertility.

Manual Vaccume Aspiration; for early pregnancy; age, parity ad illness, not contraindications
- Complications of pregnancy termination increase with elevated gestational age.

Least Invasive Method for Pregnancy Termination; Mifeprostoe and misoprostol, PgE1, this is
the least invasive method for pregnancy termination (most common method, mifepristone and
misoprostol). This is the least invasive method. –mifepristone, progesterone

Note Cu and levoegersterol; effective emergency contraception not at this gestational age.

Retained products; must do D&C, and wait 6 hours before deciding the enxt step in
management. Patient is not symptomatic from anemia.

Pregnancy Management;
This will be asymptomatic with no gestation in the uterus, the next step is to establish
pregnancy associated with D&C.
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Post operative endometritis; this can be due to introduction of bacterial products to uterine
cavity via D&C. A B-HCG is not helpful two days post termination.

Pelvic US; this is the next best step in pregnancy; note that we need to do this to elucidate the
location.

Pregnancy Termination and Prevention

Management Dilation/Evacuation with subsequent IUD placement is the best management
decision for the first trimester. While most state laws are varied, 20 weeks is permitted.

Family Planning

Methyoxyprogesterione; Depot; can cause unpredictable bleeding. Note ths resolves 203
months. Can have 50-60% with amenorrhea.

Emergency Contraceptives/Abortifactant; no teratogenic effects if administered advertently

during pregnancy. Recommended starting within 72 hours and no later than 120 hours. Plan B
can cause a few side effects.

Progestin Only Pills; this is for women who have contraindications with combined
OCPs/Estrogen pills, the contraaindicaton, thrombotic disease. Estrogen sensitive cancers and
women > 35 who smoke or women with nausea after OCPS

Combined OCPS: this will decrease womans risk of ovarian cancer/endometrial cancer----this
will be linked to slight increase in breast cancer, Note OCPS will have higher risk of CIN but risk
of PID, endometriosis, benign breast disease and ectopic is reduced,

Tubal Ligation; note that 10% of women with sterilization regret it. The strongest predictor is
young age. For those under 25, righ is as high as 40%

Contraindications to Patch;
While there is comparable efficacy in the pill with clinical trials, there is a higher failure rate.
This will release estradiol and nreestrogrimin.

LARCS: such as contraceptives and IUDs are a good option for the patient. High up front costs
for office visits (insertion/removal, LARCS have distinct advantages). May not be the best choice
with higher BMI. Can also be shown to reduce pregnancy in teens and repeat abortions.

Coppper IUD usage;

Note that the best ption for emergency contraception is IUD placement, can be placed for 5
days. This can be very useful.
Oral levonogesterol, effective if given 72 hours.
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Levogesterol; this is indicated for trans men as it removes the bleeding. This can be seen as a
discomfort to the trans population.

Obstetric Procedures;
All of the above can date pregnancy, however crown-rump length is considered to be the most
reliable. Note that 36 weeks, urine BHCG was performed, US at 13-20 weeks will comnfirm
diagnosis Progesterone can confirm whether the pregnancy is proceeding properly

Uterine Perforation; this is concerning with uterine perforation with omental damage, this
should be turned off and the tissues should be gently curetted off. Note that we should repair
immediate damage.

Fiborids; note at the lower uterine segment can obstruct labor by prevening entry into the
pelvis. This can prevent fetal head from entering the pelvis. Note macrosomia > 4000 at 42
weeks.

Placenta Previa; Management; caesarean delivery; indication for placenta previa. Other
conditions predisposing this, chorioamnitis, unfavourable cervix and PROM

Early decelerations; this will represent the fetal response to head compression during
contraction
Variable decelerations; cord compression
Late decelerations represent uteroplacental insufficiency

Tubal Ligation complication; there can be unwanted/unplanned pregnancy, this will be

postpartum tubal ligation syndrome.

Breech Infants; delivered vaginally higher risk for neonatal complications.

CVS; advantage, this can be performed in the first trimester, note that this an be available in
early pregnancy.

Cervical insufficiency; this will be typical cervical dilation; McDonald will involve a purse string
permanent suture at cervicovaginal junction.

Uteroplacental Perfusion: Experimentalstudies. Uteroplacental perfusion, growth and status;

uteroplacental perfusion affects the growth and status. There wll also be associations with HTN,
diabtes. This will be evidenced by proteinuruia.

AFI, uumbilical cord, this will reverse end-diastolic flow, these are associated with perinatal
morbidity and mortality and a higher likelihood of poor neurological outcome.

IUGR; need to do twice weekly antenatal testing. This will nclude NST, where fetal heart beat is
recorded. THis is based off the assumption of a heart rate of a fetus that does not accelerate.
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Crown-rump length; this is the most reliable dating criterion;; note that this will be documented
for weeks. Since 36 weeks, US of crown rump length will support gestational age of 36 weeks.

Morbidities associated with IUGR; this includes oligohydramnios, AFS (esophageal atresia,
anencephaly, diapraghmatic hernia or primary muscular disease,

FGR; there is association with cardiovascular disease, chronic HTN, stroke, COPD, DM and
obesity, there is also risk for cognitive decline in childhood.

NST: if the baby is responding appropriratly, then we can continue surveillance.

IUGR at 6 weeks with abnormal doppler; indication is to deliver the baby now, induction of
labor is preferred.

Macrosomia; thi will be associated with birth trauma, shoulder dystocia and brachial plexus
injury.

Obetetic US; this is the best method for fetal weight; note that this is more unreliable in the
macrosomic baby.

Post term pregnancy;

Post dates; intervention at 41 weeks of labor; this will reduce perinatal mortality without
morbidity, it will reduce caesarean delivery dates; induction of labor needs to be done

41 week US; this is likely to demonstrate normal findings; note that 5-10 % will show
uteroplacental insufficiency

Macrosomia; this will cause oligohydramnios, MAS, and uteroplacental insufficiency. There is no
consensus for induction for macrosomia.

Postterm Pregnancy; note we need to confirm the appropriate gestational age with irregular
menses, we should aim to get it at 20 weeks or SOONER to confirm the diagnosos note that low
transverse c-section are eligible for labor trial.

AMnioinfusion; normal saline is administered to intrauterine cavity; this will be 3 to 4 times

more common.

Optimal management; for a patient with a favorable cervix at 41 weeks, will do induction.

Because the patient has a unfavorable cervix and uncertain date, this can be improved. Note
that we need to do NST, or BPP
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Fetal dysmaturity; there will be chronic intrauterine malformation with long body, thin nails
and meconium stained skin/nails, dry peeling skin and small placenta. This will e with unsure
dating.

IOL: this will be done with progesterone this is the most common used cervical ripening agent;
dibgital separation and artificial membrane rupture is not recommended.

Risk for post term pregnancy; a previous post term pregnancy; others are AMA, make fetus and
Caucasian womens.

Postpartum Depression;
This includes mood changes, phobias and irritability associated with PPD rather than post
partum blues.
Risk factors; prior depression, especially because she as had it in the past. Previous PPD

Management of Severe PPD;

Inpatient hospitalization; this along with behavioural psychotherapy and SSRI/SNRI can be
done.

Fluoxitine; Can cause insomnia, also sexual disturbances, and sexual dysfunctin.

Breastfeeding/beneficial to mother and baby; note that medications can be safely used in
lactation; neglibable drugs can be used in the patient serum.

SSRI; associated with agitation, abnormal tone, tremor and temp instability.

Depressed suicidal patients; inquire always about it.

PMDD; we must be in the luteal phase of menstrual cycle; this will have depression, irritability,
anxiety and breast pain and bloating.
- Most will have emotional/physical symptoms prior to menses.

Postpartum blues; insomnia, easy crying, depression poor concentration, irritability/anxiety.