WOMEN’S HEALTH EOR-Prenatal Care/Normal Pregnancy 16%, Pregnancy Complications 15%, Menstruation 15%, Infections 12%, Neoplasms 10%,

Disorders of Breast 8%, Labor and Delivery Complications 8%, Postpartum Care 6%, Structural Abnormalities 5%, Other 5%

PRENATAL CARE/NORMAL PREGNACY 16%

Prental Prenatal Diagnosis Down Syndrome & Trisomy

Prenatal Chromosomal Abnormalities:
Diagnosis •Risk of fetal trisomy increased with
maternal age, especially after age 35
•Women with fhx or personal history
of aneuploidy should be referred to
genetic counseling
First Trimester Screening 11-14 weeks Second Trimester: 13-27 weeks Combine First & Second Trimester
•nuchal translucency: max thickness of the •enhance aneuploidy detection rates
subcutaneous translucent area b/w the skin Triple test •combines results from both trimesters
and soft tissue of spine at the back of neck, •hCG, AFP, & unconjugated estriol •highest detection of down syndrome
>3.5 is abnormal  targeted sonography, •down syndrome: •results after both completed
chorionic villous sampling, aminocentesis low AFP & estriol, high hCG
•trisomy 18: all decreased Third Trimester:
•Biochemical screening: beta-hCG, PAPP-A •spina bifida: high AFP •Gestational Diabetes: 24-28 weeks
•Downs: elevated hCG & low PAPP-A  1 hour glucola testing
•Trisomy 13 & 18: both low Quad Screen
•above + inhibin •antibody screen in Rh (-): 28wk
•ultrasound: heart tones around 10-12week •Downs: elevated inhibin *give RHOgam if negative

•Chorionic Villous Sampling: 10-13 weeks Gestational Diabetes: week 24-48 •CBC repeat: ~28wk, monitor anemia
women with increased chromosomal •UDS repeat if + initial: 28 week
abnormalities, prior child with chromosomal Aminocentesis: same as chorionic •GBS: vaginal/anal culture 36-37wk
abnormalities, materal age >35, abnormal 1st  IV PCN G at labor
or 2nd T maternal screening tests, abnormal *alternative: Clindaycin
nuchal translucency, prior pregnancy losses
Neural Tube Defects Non-Stress Testing:
Birth defects of brain: Risk Factors: Types of Spina Bifida: Baseline fetal HR 120-160bpm
•anencephaly •family history, MTHFR mutation •myelomeningocele (MC): Reactive: 2+ accelerations at rate 15+
*failure to close neural tube that •aneuploidy, diabetes, hyperthermia meninges and spinal cord herniate bpm from baseline for at 15 seconds
becomes cerebrum •medications *seizure medications through gap in vertebrae
•spina bifida Nonreactive: no fetal HR accelerations or
*incompetent closure of embryonic Screening: mom serum AFP b/w 15-20 wk •occulta: no herniation; overlying <15bpm lasting <15 seconds
neural tubule  vertebrae skin may be normal or hair; dimling •sleeping, immature, compromised
•cephalocele AFP can be affected by: or birth mark •TX: vibratory stimulation, contraction
•rare spinal fusion abnormalities •multifetal gestation stress testing
•pilonidal cyst •meningocele: only meninges
•elevated AFP in maternal and fetal •chorioangioma of placenta herniate through gap Contraction Stress Testing:
serum and amniotic fluid •placental abruption, preeclampsia Negative: no late decelerations
•AFP synthesized by fetal yolk sac •oligohydramnios, FGR Positive: repetive late decelerations
 hospitalize for fetal monitoring
Pregnancy Signs/Symptoms
Pregnancy Amenorrhea
•cessation of menses in a health
•not reliable until 10d + after menses
•can have “implantation bleeding”
for blastocyst
Vaginal/Cervical Changes
•Chadwick: mucosa appears dark
bluish red & congested
•Goodells sign: cervical softening
•cervical mucus: thick due to P
•uterine change:
•Haegers sign: isthmus soften (6-8)
•Ladin sign: uterus softens (6wk)
Estimate Date of Delivery
•Naegele’s Rule
-LMP + 7days – 3 months
-assumes pregnancy begun
2wk before ovulation
•Ultrasound
 1st trimester crown rump
is MOST ACCURATE
Breast Changes
•tenderness & paresthesia
•increase in breast & nipple
•thick yellowish fluid  colostrum
•areola becomes deeply pigmented
Skin Changes ~16th wk
•increased pigmentation, linea nigra
•pruritic papules  steroids
•chloasma  “mask”
•striae (stretch marks)
Fetal Movement 16-20 weeks
•Primigravida ~20wk
•Multigravida ~16-18wk
Heart Tones: 10-12 weeks
Prenatal Visit
History
•obstetrical hx: pregnancies,
complications, infertility
•menstrual: interval between menses,
contraceptives
•fhx, shx, medical hx
Physical Exam
•uterine size *bimanual
-small orange ~6wk
-large orange ~8wk
-grapefruit ~12wk
•cervical dilation, length, consistency
*bimanual
•pelvic architecture *bimanual
Diagnostic Tests
Beta human chorionic gonadotropin (B-hCG) Transvaginal US
•produced by syncytiotrophoblasts gestational sac: small anechoic
•blood and urine about 8-9d after ovulation fluid within endometrial cavity
•prevents involution of corpus lutem  first evidence ~4-5wk
•rare false (-): MCC is herephilic antibodies yolk sac: bright echogenic ring
*urine would be negative with anechoic center
•false (+) causes: exogenous hCG, renal failure with  confirms location ~5-6wk
failed hCG clearance, pituitary hCG, tumors fetal pole/embryo: ~6wk
*home pregnancy tests require value of 12.3 to crown rump length: used up to
detect 95% pregnancies  use 1st urination 12wk to predict the due date,
accurate within 4d
Lab Tests RhoGam
First Visit MOA: suppresses immune
•CBC: WBC, Hgb, Hct, Plt response of Rh negative
*monitor anemia & thrombocytopenia individuals to Rh (+) RBCs
Blood type and Rh Factor: if Rh (-) mother and Rh Dose: 0.3mg eradicates 15ml of
(+) fetus then receive RhoGam ~28thwk *RhD fetal RBC
•antibody screening
Should be given
rubella serology: infection in 1st semester can cause -bleeding or trauma prior to 28wk
abortion, malformations -postpartum if infant Rh (+)
-invasive diagnostic prenatal test
•pap smear
•gonococcal & chlamydia, syphilis, HIV, hepatitis Keihauer-Betke
•urinalysis •tests amount of fetal RBC in
•urine culture & sensitivity maternal circulation
Counseling
Prenatal Vitamin
•400 micrograms of folic acid
*4mg if hx neural tube defect
Employment
•work until labor
Weight Gain
•Maternal weight gain is correlated
with infant weight
*obese women who gain <15lb have
the lowest complication rate
*25-35lbs, underweight: 28-40lbs,
obese: gain around 12-20lbs
Obesity associated risks:
•gestational HTN, DM, preeclampsia
•macrosomia
•C-section
Routine Care
•Every 4 weeks until 28 weeks
•Every 2 weeks until 36 weeks
•Every week unil delivery
Prenatal Surveillance
At each return visit:
•US fetal growth (dating & anatomy)
•maternal BP/weight
•U/A, protein, glucose
•S/S: leak, contractions, N/V, bleed
Diet: additional 100-300kcal/day
- 60-80g protein/day
Seafood
•avoid fish and shellfish contain mercury
•High risk: shark, sword, mackerel, tile fish
•no more than 6oz of white tuna
Lead
Risk factors:
-recent immigrant
-living near lead source
-using lead glazed pottery
-eating nonfood substances
-using imported cosmetics
-remodeling home with lead
-consuming lead water
-living w/ someone with elevated lead
Common Complaints
Nausea/Vomiting “morning sickness”
•common in 1st trimester until 16th wk
TX: small meals, BRAT diet, ginger,
vitamin B6 + Doxylamine, Zofran
•Hyperemesis gravidum: vomiting severe that
dehydration, electrolyte, and acid-base
disturbances and starvation ketosis
•hypokalemic, hypochloremic metabolic
alkalosis
Back Pain *low back pain
•increased with gestational age
•Reduce By: squatting rather then bending,
avoid high heels, use a pillow back support,
belly band, PT, Tylenol prn
Seat Belt
three point restraints with lap belt under
abdomen and across upper thigh
Air Travel
can fly up to 36wk, ambulate hourly and
wear TED hose
Dental: no CI including x-rays
Coitus (intercourse): not harmful
Caffeine: >5c can increase abortion,
<200mg (10oz) not associated with issues
Exercise
•do not limit; engage in moderately intense
activity for 30min+/day; *don’t lift >25lb
•avoid: high risk falling or trauma & scuba
Hemorrhoids
•increase in pelvic venous pressure, rectal
vein varicositis occur
•pain and swelling occur
TX: topical applied anestheics, warm soaks,
stool softeners
Varicosities
•femoral venous pressure in pregnant woman
increased 8  24mmHg at term
•cosmetic blemished to severe discomfort
TX: rest with leg elevation, elastic stocking
Smoking: person to person counsel
•ask, advise, assess, assist, arrange
Alcohol: MC in white; NO ALCOHOL
Illicit Drugs: less likely to obtain prenatal care
Breastfeeding
•exclusive BF preferred until 6mo
•human milk contains protective
immunological substances  IgA and GF
•protects against rotavirus, decreased atopic
dermatitis and resp infections
CI: street drugs, uncontrolled alcohol,
galactosemia, HIV, TB, medications, breast
cancer treatment, active herpes on breast
Heartburn *very common
•GERD in lower esophagus due to upward
displacement & compression of stomach
TX: antacids, H2 blockers, PPIs
Pica: craving for strange food  iron def.
Sleeping & Fatigue:
•efficiency declines with gestational age,
increase need
TX: Benadryl, daytime naps
Leukorrhea: increase discharge
Labor About
Labor •The physiologic process by which
a fetus is expelled from the uterus
3 Stages:
•Stage 1: onset  full dilation
•Stage 2: full dilation  delivery
•Stage 3: delivery  placental
delivery (0-30min after)
Cervical Exam
Dilation: 0-10cm (10 is complete)
Effacement: length of cervix
•difference b/w internal and external os
Station: degrees of descent of fetus
•measure in cm from ischial spines
•measure it in thirds -5  +4
Consistency: soft, medium, firm
Position: Anterior, mid, posterior
Diagnosis of Labor
•In order to diagnose labor, THERE MUST BE Status of Membranes:
CERVICAL CHANGE! •ferning, nitrazine, pooling, AFI
•spontaneous rupture of membrane
•contractions without cervical change  (during labor), PROM (before labor)
Braxton Hicks contractions •vaginal bleeding
Bishop score: determines how favorable the Group B Strep:
cervix is for labor •36-37 weeks with cervical-ano swab
(+)  treat in labor with Penicillin
•allergy, obtain sensitivities:
Clindamycin or Erythromycin
•no sensitivities: Vancomycin

1st Stage About Methods

Induction •Attempt to begin labor in a non- Prostaglandins Later Induction-Pitocin (IV) Balloon catheter (Cook)
of Labor laboring patient •Cervidil (PGE2, vaginal) •identical version of oxytocin released from
•Cytotec (PGE1, vaginal or oral) posterior pituitary to lead to uterine contracts Laminaria: use when the mother
CI: •help ripen and dilate cervix (dissolution of has had a miscarriage;
•myomectomy collagen & increases water uptake) SE: tachysystole (>5 contraction in 10
•placenta previa minutes), uterine rupture, hyponatremia, Artificial rupture of membrane
•prolapsed cord SE: tachysystole, fever, V/D, uterine rupture hypotension, amniotic fluid embolism -amnio hook used to puncture sac
•active genital herpes * risk-umblical cord prolapse
•transverse fetal lie CI: hx c-section, myomectomy, hysterectomy CI: fetal distress, hypersensitivity
•uterine scar from C-Section incision
and cephalopelvic disproportion

Pain Spinal Anesthesia Pudendal Block Epidural: catheter placed in L3-L4 space General Anesthesia
•one time dose placed directly into •provides perineal anesthesia •used for C-section in emergent or
the spinal canal •used with operative vaginal deliveries or for complications: maternal hypotension, urgent setting or when CI to
•used for C-section extensive perineal repairs after maternal respiratory depression, spinal HA regional anesthesia
•complication and CI similar to (treat with blood path, fluids)
epidural complications:
CI: bleeding disorder, LMWH w/n 12h, •maternal aspiration
patient refusal •risk of hypoxia to mother & fetus
 About
First Onset of labor to complete cervical dilation
Stage of
Labor Freidman’s Labor Curve:
•Latent phase: onset of labor  4cm
•active phase: 4cm complete dilation (10cm)
*faster rate of cervical change
nulliparous: 1.2cm, multiparous: 1.5cm
•3 Ps: passenger, pelvis, power
Pelvis (Passage)
•Bony pelvis & soft tissues of the birth canal
(cervix, pelvic floor muscle)
•small pelvic outlet can cause cephalopelvic
disproportion
•bony pelvis can be measured by pelvimetry
*not accurate
Abnormalities:
•cephalopelvic disproportion
-passenger is too large, indication for C-section
Abnormalities
Arrest of dilation & descent:
•indications for C-section
Umbilical Cord Prolapse:
•prolapse of umbilical cord in front
of fetal head
•risks: artificial rupture of
membranes, unengaged fetal head
•EMERGENCY  C-section
Power
Uterine Contractions
•force generated by uterine
myometrium
•contraction force can be measured
by direct measurement of
intrauterine pressure urince and
internal pressure monitor (IUPC)
•3-5 contractions in a 10minute
period is adequate for labor
•adequate labor >200montevideo
units in 10 minutes  only measure
in IUPC
Abnormalities:
•if labor is not progressing, insert
IUPIC; if <200montevideos in
10min  Pitocin
Labor Augementation
•intervening to increase the force of
the already present contractions
 Pitocin, AROM
Passenger
Passenger (Fetus):
Fetal variables that can affect labor
•fetal size (macrosomia) and fetal lie
(longitudinal, transverse, oblique)
•fetal presentation: vertex, breech, shoulder,
compound and cord
•attitude: degree of flexion or extension of
the fetal head
•position: relationship between the fetal part
to the R or L side of the birth canal
-vertex: occiput is reference
-breech: sacrum is reference
•station
•number of fetuses
•presence of fetal anomalies
Heart Rate Monitor
•Normal fetal HR: 110-160bpm
•Bradycardia : FHR <110bpm
-causes: heart block maternal hypotension
Tachycardia: FHR >160bpm
-Causes: infection, Terbutaline
Baseline: mean bpm over 10 min window
Absent: 0bpm of variation (BAD)
Minimal :1-5bpm of variation *sleeping
Moderate: 5-25bpm of variation
Marked: >25bpm of variation (BAD)
Accelerations:
• >32 weeks: at least three 15bpm above the
baseline and lasting for 15 seconds
• <32 weeks: at least three 10bpm above the
baseline and lasting for 10 seconds
•Leopolds maneuver
-mother lies supine
-can determine: fetal lie,
estimate fetal weight, fetal
position, fetal presentation
*difficult in obese mother,
polyhydramnios, multifetus
•Vaginal exam: palpation
•Ultrasound *MC today
Abnormalities:
•any position other than vertex
usually results in a C-section
•macrosomia (>5000g or 4500 in
diabetics) should have C-section
Decelerations:
Early: begin and end approx. at
the same time as contractions
-result of head compression
Late: peak of contraction, return to
baseline after contraction done
-uteroplacental insufficiency
-require intervention
Variable: anytime, drop more
precipitously cord compression
-possible intervention:
amniofusion (saline into sac)
Sinusoidal Waveform: sine wave
•cause: fetal anemia
2nd Stage About Seven Movements
Cardinal •Changes in the fetal head position Engagement: Internal Rotation: External Rotation/Restitution:
Movements during its passage through the canal •passage of widest diameter fetal presenting •rotation of the fetal head from •As the head is delivered, it rotates
of Labor part below pelvic inlet occiput transverse to occiput anterior back to its original position
Seven Movements: •head at level of the ischial spine (zero station) to posterior position •head aligns anatomically with
-engagement •occurs passively the fetal torso
-descent Decent (lightening) •release of the passive forces on the
-flexion •downward passage of the presenting part Extension: fetal head allow it to return
-internal rotation through the bony pelvis •occurs when the fetus has descended
-extension to the level of the vaginal introitus Expulsion
-external Flexion: •when the occiput is past the level of •delivery of fetus
rotation/restitution •occurs passively as the head descends due to symphysis, the angle of the birth •downward traction allows released
-expulsion the shape of the bony pelvis canal changes to upward position of the anterior shoulder
•complete flexion allows the fetal head’s
smallest diameter to fit through
(suboccipitobregmantic diameter)

Labor About Examining Fetal Head Laceration Third and Fourth Stage
Second , •Interval between full cervical Molding: alteration of fetal Perineal Lacerations: Third Stage
Third, dilation to delivery of the cranial bones as a result of 1st degree: perineal skin and vaginal mucosa • fetal delivery to placenta delivery (0-30 min)
Fourth infacnt compressive forces of pelvis 2nd degree: injury to perineal body
Stage of 3rd degree: through external anal sphincter Three signs of placental separation:
Labor •characterized by descent of the Caput: localized edematous area 4th degree: injury through rectal mucosa 1. lengthening of umbilical cord
presenting part through the on the fetal scalp caused by *3rd and 4th degree require surgery 2. gush of blood
maternal pelvis and expulsion of pressure by the cevrix 3. fundus becomes globular and more anteverted
the fetus against abdominal hand

Indications: •Placenta is delivered using one hand on

•pelvic/rectal pressure “need to
push”
•mother has active role of
pushing to aid in fetal descent
Lightening: fetal head
descending into pelvis changes
abdomens shape and sensation
that baby has “become lighter”
Bloody Show: passage of blood-
tinged cervical mucus late in
pregnancy when cervix thinning
Episiotomy:
•surgical incision of female perineum
•increases diameter of soft tissue pelvic outlet to
allow delivery
•rationale: reduce 3rd and 4th degree lacerations,
•indications: fetal distress
•complications: vaginal bleeding, increase
potpartum pain, unsatisfactory anatomic results,
sexual dysfunction, infections
•types: midline, mediolateral (MC)
umbilical cord with gentle downward traction
other hand on abdomen supporting fundus
•Risks for traction-EMERGENCY
-immediate replacement of fundus
Fourth Stage
•Time from delivery of the placenta to ONE
hour immediately postpartum
Monitor: blood pressure, uterine blood loss,
pulse rate q15minutes for 2 hours
Fundal Height: 12 weeks (above pubic symphysis), 16 weeks (midway between pubis & umbilicus), 20 weeks (umbilicus), 38 weeks (2-3cm below xiphoid

APGAR Score: 7+: normal, 4-6: fairly low, < 4: critically low
A: appearance: blue grey (0), body pink/blue extremities (acrocyanosis) (1), pink (2)
P: pulse: none (0), <100 (1), 100+ (2)
G: grimace: no response to stimulation (0), grimaces freebly (1), pulls away/sneeze/cough (2)
A: activity: no muscle tone (0), some flexion (1), flexes arms and legs (2)
R: respiration: absent (0), weak & irregular (1), stron crying (2)

OBGYN About Clinical Presentation Care and Disposition Management

Multiple •gestational trophoblastic disease Dizygotic (fraternal): fertilization of 2 ova Ultrasound: visualize fetuses Maternal Complications: preterm labor,
Gestations •rapid maternal weight gain and by 2 different sperm spontaneous abortion, preeclampsia,
growth of uterus B-HCG: elevated anemia
Monozygotic (identical): fertilization of 1 AFP: elevated
ovum that splits Fetal Complications: IUGR, placental
abnormalities, breech, umbilical cord
prolapse, preeclampsia

Gravida: number of times a woman have been pregnant

Parity: Number of pregnancies that led to a birth either at or after 20 weeks
- T (term)  number born at 37 weeks or older
- P (preterm)  born after 20 weeks but before 37 weeks
- A (abortion)  all pregnancy losses prior to 20 weeks
- L (living)  infant who lives beyond 30 days

Nulligravida: woman who currently is not pregnant and never has been pregnant
Primigravida: woman who currently is pregnant and has never been pregnant before
Multigravida: woman who currently is pregnant and who has been pregnant before
Nullipara: woman who has never completed a pregnancy beyond 20 weeks
Primipara: woman who has delivered a fetus or fetuses born alive or dead with an estimate length of gestation of >20weeks
Multipara: woman who completed 2+ pregnancies to 20 weeks gestation or mo
PREGNANCY COMPLICATIONS

OBGYN About Clinical Presentation Diagnostics Management

Incompetent •premature cervical shortening
Cervix or dilation in the second or early
(Cervical third trimenters (up to 28wk)
Insufficiency
) Risks:
•hx cervical insufficiency
•hx injury, surgery, conization
•DES exposure in utero
•anatomic abnormalities
•significant cervical dilation (>2cm)
•minimal contractions until 4cm
•bleeding or vaginal discharge
(especially in the 2nd trimester)
Exam: PAINLESS dilation &
effacement
TVUS: most accurate & predicitive
•done at 14-16 weeks o earlier
•wide internal os, shortening of canal,
hourglass, bulging of fetal membrane
•cervical length <25mm before 24wk
Cerclage (purse string suturing of os) &
bed rest
*confirm vitable intrauterine pregnancy
before placing
*culture of G/C and GBS before place
CI: infection, ROM
•weekly 17 alpha-hydroxyprogesterone
injection in some women

OBGYN About/Rsiks Presentation Diagnostics Management

Placental Separation of the placenta either partially or •Sudden onset of •DIAGNOSIS OF EXCLUSION •fluids and blood if needed
Abruption totally from its implantation site before delivery abdominal PAIN •CBC, CMP, PT/PTT/INR, blood type •emergenct OBGYN consult
•vaginal bleeding -possibly emergent C-section
Cause: hemorrhage into decidua basalis •uterine tenderness •transabdominal US  TVUS
Complications:
Risks: MCC bleeding in THIRD •May be associated with elevated AFP •hypovolemic shock
•materal HTN TRIMESTER •DIC
•trauma, uterine fibroids, lupus Speculum and digital pelvic exam CI •AKI (hypovolemia)
•increasing maternal age, past aborption Exam: unltil US r/o placenta previa •Couvelair uterus: extravasation of
•Preeclampsia, smoking, cocaine •tender, rigid hypertonic blood into uterine musculature &
uterus beneath serosa
•NO PELVIC EXAM -myometrium “blue-purple” tone

Placenta Placenta that is implanted either over or near •PAINLESS vaginal

Previa internal cervical os bleeding usually after the C-Section performed in complete,
second trimester (28 wks) major degrees, and fetal distress
Classifications:
•Placental previa: os covered partial or complete *uterine body is
•Low-lying: implantation in lower uterine segment remodeling to form the
•partial: partial coverage lower uterine segment 
•marginal: adjacent to internal os (<2cm away) internal os dilates 
bleeding occurs
Risks: maternal age, mult. gestations, C-section,
smoking, high MSAFP, preveious previa
OBGYN About
Ectopic •leading cause of maternal
Pregnanc pregnancy-related death in
y 1st trimester
•pregnancy outside uterine cavity
•MC in ampulla of fallopian tube
Risk Factors
•previous ectopic pregnancy
*strongest risk factor
•PID, STDs
•surgery on fallopian tubes
•IUD, infertility treatments
Suspect in any female of
childbearing age with
abdominal/pelvic pain or bleeding
Molar •neoplasm due to abnormal
Pregnanc placental development with
y trophoblastic tissue proliferation
Complete: Diploid 46XX: empty
egg with no DNA, all paternal
chromosome  absence of fetal
tissue
Partial/Incomplete:
Triploid 69XXX or XXY: egg
fertilized by 2 sperm, fetal tissue
may be seen but abnormal
Risks: prior molar, extreme ages
(<20, >35), Asians
Chorio- Cancer of gestational contents
carcinoma
Clinical Presentation
Clinical Presentation
TRIAD: unilateral pelvic pain, vaginal
bleeding, amenorrhea
•light or heavy vaginal bleeding
•diffuse pain  peritonitis after rupture
• referred shoulder pain or upper abdomen
Physical Exam
•hypotension, hypovolemia, or shock
•localized or generalized tenderness
•cervical motion tenderness, adnexal
tenderness with or without mass
•painless vaginal bleeding
•preeclampsia before 20wk
•hyperemesis gravidarum *elevated b-hCG
Exam:
•uterine size and date discrepencies
Care and Disposition
Diagnostics
•b-HCG >1500
*serum is best
*does NOT double q48h like normal
•vaginal US
-transvaginal is best
*beta level of 1500 & empty uterus
Transvaginal US:
•empty uterus with adnexal mass w/
or w/o free fluid in the abdomen
•empty uterus without adnexa mass or
free fluid with a (+) pregnancy test
Labs:
•b-hCG: super high >10,000
Pelvic Ultrasound
•complete: central heterogenous mass
w/ multiple discrete anechoic spaces
“snowstorm” or “grape cluster”
•partial: gestational sac and fetal
heart tones + abnormal tissue
*confirm with biopsy
•elevated B-hCG
Pelvic Ultrasound:
•uterine size much larger than
expected for dates
*confirm with biopsy
Management
•discharge if beta <1000
•laporoscopcie exam or medical
management with MTX
Methotrexate:
Must be:
•aymptomatic, motivated, compliant
•low b-hcg (<5000), small (<3.5cm)
•absent fetal heart activitity
•no intrabaomdinal bleding
Surgery
•Laparoscopy (PREFERRED!) -
-salpinostomy: tubal salvage
-salpingectomy: tube resection
•surgical uterine evacuation
•follow weekly until b-hCG drop
*obtain CXR to look for mets
(choriocarcinoma)
•Resect by suction curettage
•Methotrexate, Actinomycin
OBGYN About Work-Up Care and Disposition
Spontaneous Threatened: *only one potentially viable Pelvic Exam hemodynamically unstable: Complete Abortion:
Abortion •products of conception intact •caution in patients beyond 20 -emergent consult •may be discharged home if stable and
•cervical os closed weeks because risk of placentia -fluid and blood vaginal bleeding is decreasing or absent
Pregnancy previa -Rhogam if RH (-) •pelvic rest
that ends <20 Inevitable: •close follow up with OB
WEEKS •products of conception intact Labs: Types •Rhogam if indicated
gestation •bleding, cramps, os dialted •CBC Threatened Abortion:
•blood typing and crossmatch •pelvic rest Setpic abortion
Incomplete: •Rh factor •may be discharge home with •obtain CBC, blood and uterin cx, LFTs,
•some products expelled •B-hcg close follow up with OB BMP, PT/PTT
•bleeding, cramping, os dilated •Urinalysis •return to ED if significant pain, •OB/GYN consult and asmiddion
fever, vaginal bleeding, passage •Ampicilling/Sulbactam
Complete: Ultrasound of tissue •Clindamycin + Gent
•products of conception expelled transabdominal or transvaginal
•cervical os closed •may confirm fetal death by Inevitable: Incomplete/Missed:
noting evidence of fetus with no •surgical evacuation (D&C) •surgical evacuation (D&C)
Missed: fetal death <20 wks, brownish heartbeat or movement •Misoprostol •Misoprostol
discharge, no fetal tissue is passed •expectant management •expectant management
•US should sac with no heart beat

Septic Abortion MCC incomplete

evacuation
•some products of conception retained
•cervical os closed; cervical tenderness
•brown, foul discharge; fever, chills

RH Allo- •when Rh(D) negative women carry a Antibody Screen: Prevention:

immunizatio Rh(D) positive fetus •initial prenatal visit low: repeat in 2-3 weeks •anti-D Rh immunoglobulin 3x:
n •repeat at 28 weeks if (-) medium: repeat in 1-2 weeks 1. 28 weeks
Pathophysiology: high: percutaneous umbilical 2. w/n 72h delivery of Rh (+) baby
•in subsequent pregnancy, the antibodies Antibody Titers: (-) women blood sample, low htc  3. after potential blood mixing
will cross palcenta and attack fetal RBC  •unsensitized: no antibodies intrauterine umbilical vein (spontaneous abortion, ectopic
hemolysis of fetal RBC •sensitized: titers performed via infusion pregnancy, aminocentesis)
indirect antiglobulin test
At-Risk: (-) mother, (+) father or unknown *1:16+, aminocentesis 16-20 wk
Gestational diabetes: Diagnosis of diabetes during pregnancy that is not clearly TI or TII
Screening & Diagnosis
Gestational 2 step method
Diabetes •50g 1 hour oral glucose challenge
test between 24-28 weeks
-not affected by fasting
-test women with risk factors
•if (+) 1 hour test  100g 3 hours
glucose tolerance test
Diabetes About/Risks
Pregestational •diabetes before pregnancy
Diabetes •effects related to control
Fetal Effects:
•spontaneous abortion
•malformations:
•altered growth (macrosomia)
•polyhydramnios
Neonatal Effects:
•respiratory distress syndrome
•hypoglycemia *drop after
-glucose crosses placenta
-infant overproducing insulin
•hypocalcemia
•hyperbilirubinemia
•cardiomyopathy
Maternal Effects:
•preeclampsia, preterm delivery
•diabetic nephropathy,
retinopathy, neuropathy. DKA
3 hour glucose tolerance test
•need 2 abnormal results
-fasting: 95
-1 hour: 180
-2 hour: 155
-3 hour: 140
First Trimester:
•glucose monitoring
-fasting <95
-premeal <100
-1h postprandial <140, 2h <120
-A1C <6
•Manage with Insulin
•Maternal echo, baseline 24h urine
Second Trimester
•maternal serum AFP b/w 16-20wk
•targeted US b/w 18-20 weeks
•fetal echo b/w 20-24 weeks
•continue glycemic control
*consider insulin if on oral meds
Treatment and Management
Glucose: Monitor blood glucose
•fasting <95 and 2h postprandial <120
•diet & exercise (1st line)
Medication: insulin, Glyburide, Metformin
Delivery:
•C-section can be considered in gestational
diabetics if fetal weight >4500g
•increased evidence of shoulder dystocia
Third Trimester:
•Initiate antepartum testing 32-34weeks
-earlier if uncontrolled
-NSTs with AFIs done weekly
•growth monitored every 4 weeks
Delivery: 38 weeks
•insulin drop not needed
•vaginal or C-section
Potpartum
•insulin may need to be decreased by
half and monitored closely
•risk of infection is increased
Postpartum:
•all women should get 75g 2 hour glucose
tolerance test at 6-12 weeks
Maternal and Fetal Effects:
•increase rate of stillbirth
•fetal macrosomia
•neonatal hypoglycemia
•maternal obesity
•high plasma glucose levels, glucosuria,
ketoacidosis
•random plasma glucose >200 plus
polydipsia, polyuria, wt loss
•fasting glucose >125
•HbA1C 6.5%+
Preconceptional Care
GLUCOSE!
•preprandial: 70-100
•peak postprandial: 100-129
•mean glucose <110
•HgA1C <7
•Folic acid 400micrograms/day
OBGYN About Clinical Presentation Treatment
Preeclampsia •new onset HTN (>140/90) occurring Mild: BP 140/90 + 300mg proteinuria in 24hr Mild:
/ Eclampsia AFTER 20 weeks gestation + proteinuria >37 weeks gesation: deliver
Severe: BP 160/110 + 5g proteinuria in 24hr <37 weeks: daily weights, weekly BP and dipstick
•BP on 2 occassions, 4 hours apart •end-organ damage (visual)
•renal insufficiency Severe:
Risks: HTN, nulliparity, <20 or >35yo, >37 weeks: delivery + Magnesium sulfate + Labetolol
DM, CKD, autoimmune HELLP: Hemolytic anemia, Alevated LFT, Low Platelets 34-37 weeks: delivery

Eclampsia: preeclampsia + tonic-clonc seizures or coma Eclampsia: IV Mag, IV Labetolol, delivery

Chronic “Preexisting HTN” >140/90 •usually asymptomatic Mild:

(Preexisting) presents BEFORE 20 weeks or longer •monitor every 2-4 weeks, then weekly at 34-36 weeks
Hypertension then 12 weeks postpartum Mild: 140/90
Moderate: 150/100 Moderate/Severe:
•BP falls early, then rises in 3rd trimester Severe: 160/110 •Labetolol, Nifedipine, Methyldopa, Hydralazine
•high vascular resistance, reduced •NO ACEI OR ARB
intravascular volume

Gestational “transitional hypertension” •asymptomatic •weekly blood pressure, urine protein, platelets, LFT
Hypertension •US monthly; weekly fetal nonstress test in 3rd trimester
BP >140/90 AFTER 20 weeks in prev. Diagnostics: urine protein, LFT, fetal status
normotensive women *differentiate from pre-eclampsia Severe HTN: medication
MENSTRUATION

Menstrual Cycle:
•Menstruation: day 1
- corpus luteum deteriorates  rapid fall in progesterone & estrogen  endometrium sloughs, negative feedback of GnRH casusing pulsatile increase in GnRH  increase FSH/LH

•Follicular (Proliferative) Phase: days 1-14 *estrogen predominates

- Estrogen: pulsatile GnRH from hypothalamus  increase in FSH and LH from pituitary glands
- Ovaries: increase FSH causes follicle and egg maturation
- Endometrium: estrogen build up the endometrium (thickens)

•Ovulation: estrogen released from mature follicle  positive feedback  increased estrogen, LH, and FSH  LH surge causes ovulation

•Luteal (Secretory) Phase: days 14-28 *progesterone predominates

- Progesterone: LH surge causes ruptured follicle to become corpus luteum  secrets progesterone & estrogen
- Ovaries: ruptured follicle matures and becomes corpus luteum, secreting progesterone
- Endometrium: progesterone enhances the lining of the uterus
- Pregnancy Occurs: blastocyst (maturing zygote) keeps corpus luteum functional
- No implantation: corpus luteum degenerates  steep decrease in estrogen & progesterone  menstruation
 Estrogen
Hormones 3 major estrogens in women:
•Estrone (E1): main estrogen in post-
menopausal women who are not on HRT
•Estradiol (E2): major secretory product of
ovary; fluctuates widely during menses &
drops after menopause
•Estriol (E3): major estrogen in pregnancy
*looks for complications in pregnancy
Progesterone
•E1: antiestrogen therapy, adjunct assessment of Corpus Luteum: Placenta:
fracture risk, disorders of sex steroid •after ovulation •secretory in pregnancy end
metabolism, delayed or precocious puberty •determines if ovulation of 1st T
*rarely drawn occurred & menopausal status •evaluation of placental
function in pregnancy
•E2: antiestrogen therapy, disorders of sex steroid Adrenal glands:
metabolism, evaluate ovarian function, •converts to other steroids
monitoring HRT, cirrhosis & hyperthyroidism •does NOT contribute to serum •High biotin can cause false
levels readings
•E3: quad screen, fetal pathology, marker for •use in adrenal tumor w/u
fetal demise, assess preterm labor risk

FSH and LH Prolactin Hyperprolactinemia

S/S of hyperprolactinemia:
•FSH- gametogenesis and ovarian cycle Function: initiation & maintenance of lactation Physiologic Increases
•loss of libido
•sleep, exercise, sex
•galactorrhea
•LH- ovarian cycle and initial maintenance of Inhibited naturally by DOPAMINE •nipple stimulation
•infertility
luteal function for first 2 weeks of pregnancy •Any dopamine antagonist may increase prolactin *positive feedback
•decreased muscle mass
•Serotonergic drugs can increase prolactin •hypoglycemia
•osteoporosis
 In males - promotes testosterone synthesis
High: COMP
•Ovarian hypofunction/hypogonadism
•Menopause, Castration, Precocious puberty
Low: PAP HO
•Pituitary failure, Hypothalamic failure
•Pregnancy, OCPs
•Anorexia/malnutrition
OBGYN About
Premenstrual PMS: cluster of physical, behavior,
Dysphoric and mood changes with cyclical
Disorder occurrence during luteal phase of
menstrual cycle
PMDD: severe PMS with functional
impairment
OBGYN About
Amenorrhea Primary:
•absence of menses by age 13 (if
sexual development impaired) or age
15 (if normal sexual development)
Causes: abnormal chromosomes,
hypothalamic hypogonadism
Secondary:
•absence of menses for >3 cycles or 6
consecutive months in a previously
menstruating patient
Causes: pregnancy, galactorrhea,
PCOS, pituitary/hypothalamus disease
•Antihypertensive drugs with high CNS •postpartum, newborn
concentrations can increase prolactin In men: *got moms prolactin
•impotence •lactation
•
In women: Pathologic Increases
•Oligomenorrhea •pituitary, hypothalamic
•amenorrhea •chest wall lesions
•primary hypothyroidism
•renal failure
•medications
Causes Diagnostics Treatment
•Physical: bloating, fatigue, breast swelling •lifestyle modifications Premenstrual Dysphoric
or pain •SSRI (1st line for emotional) Disorder
•Emotional: irritability, depression, •OCPs (Drospirenone contain)
anxiety, hostility, libido hanges,
aggressiveness
•Behavioral: food cravings, poor
concentration
Diagnosis: onset 1-2 weeks before menses,
relevied day 2-3 menses, 7 days free during
follicular
Causes Diagnostics Treatment
Hypothalamic-Pituitary Dysfunction Primary: b-hCG and FSH •correct underlying cuase
•GnRH deficiency, pituitary dysfunction (+) secondary sec characteritics
•hyperprolactinemia 1. Check if uterus present if desire pregnancy:
•Sheehans syndrome: postpartum pituitary 2. karyotype •ovulation induction
necrosis due ot hypovolemia (Clomiphene (Clomid))
(-) sex characteristics
Ovarian 1. Check FSH and LH If not desiring pregnancy:
•gonadal dysgeniesis, ovarian failure, PCOS -low: hypogonadotropic hypogonad •estrogen/progesterone
•abnormal steroids, abnormal hormons -high: hyper (combo oral contraceptives)
2. Karyotype if FSH/LH high
Anatomic
•Mullerian Dysgenesisi: congenital absence Secondary: b-hCG
of the uterus and upper 2/3 of the vagina 1. pregnancy test
•vaginal agenesis, transverse vaginal septum 2. TSH and prolactin
•Ashermans syndrome: uterine adhesions •Progesterone challenge test: if
bleeding occurs, endometrium intact but
Uterus Present & Breast Present: progesterone is lacking
•outflow obstruction (hymen) •Estrogen + Progesterone challenge:

Dysfunctional •abnormal menstrual bleeding and
Uterine bleeding due to underlying causes
Bleeding
Anovulatory: ovaries produce estrogen
but no ovulation *no corpus luteum
•unopposed estrogen leads to
endomertrial growth & shedding
Dysmenorrhe •painful menstruation that affects
a normal activities
Primary: due to increased
prostaglandins
Secondary: due to pelvis or uterus
pathology (endometriosis, PID,
adenomyosis, leiomyomas)
Menopaus Definitions
e
Menopaus •Cessation of menses for >1 years due
e to loss of ovarian function  low E & P
Risks:
•smoking (advanced age by 2 years)
•reproductive tract disease
•GU infections or tumor
•chemo, readiation, surgical procedures
•ovary blood supply, endocrine, genetic
Stages:
Climacteric: phase when woman passes
from reproductive to nonreproductive
“climacteric sx or complaints”
Menopausal Transition: climacteric
phase before menopause when
Uterus Present & Breast Absent:
•elevated FSH, LH (ovarian)
•normal/low FSH, LH (HPO)
Uterus Absent & Breast Present:
•Mullerian (46XX), Androgen (46XY)
Uterus Absent & Breast Absent: rare
Abnormal bleeding with relatively normal
physical exam
•mass or enlarged irregular uterus:
leiomyoma
•symmetrically enlarged uterus:
adenomyosis, endometrial cancer
•recurrent, crampy midline lower abdominal
pain or pelvic pain 1-2 days before or at
onset of menses
•diminished over 12-72 hours
Hormone/HPO Axis Change
•loss of oocytes as ovaries age due to
ovulation and atresia
-7 million at 20 weeks
-1-2 million at birth
-300.000-500,000 by puberty
-400-500 ovulated
•as ovaries lose oocytes, levels of
inhibin slowly decrease
(less inhibin  increase FSH)
*inhibin inhibits FSH
•Oocytes responsive to gonadotropins
disappear from the ovary over time
-remaining oocytes: less
responsive to FSH and LH
-irregular follicle response to
bleeding means hypogonadism
•FSH and LH
-high: primary ovarian failure
-low: secondary ovarian failure
•beta-hCG
•CBC: H/H
Endometrial Biopsy:
•rule out cancer in all women >35 wih
obesity, HTN, or DM with
postmenopausal bleeding
Hormones
ANDROGRENS
•less production of androstenidone
(primary androgen in women)
•decreased levels of testosterone
*less sex hormone-binding globulin
 more active floating around
ESTROGEN: *draw estradiol
level
•reduced endogenous estrogen
•greatest decrease in estradiol
*primarily secreted from adrenal
•estrone levels fall, but not as much
*estrone is predominant estrogen
after menopause
PROGESTERONE
Acute Hemorrhage:
•IV estrogen (Premarin)
•observation, COCs
•refractory: IUD
•definitive: hysterectomy
Postmenopausal:
•exogenous hormones
•atrophy: lubricants
Supportive:
•heat compress
•vitamin B, E
NSAIDs/COCs:
•first line medical manage
Laparoscopy: unresponsive to
3 cycles of initial therapy
Clinical Presentation
Menstrual: irregular, short/long
Somatic: HA, dizzy, palpitations, breast
pain/enlargement, joint pain
Psych/Cognitive: sleep, depression,
irritable, mood swings, memory
Sex: vaginal dryness, low libido
*vaginal atrophy due to low E
vasomotor: hot flashes, sweats
Other: incontinence, dry/itchy skin, hair
loss, hirsutism, wt gain, decreased bone
density, decreased breast size
 menstrual cycle is irregular
(“perimenopause”)
•lasts about 1-3 years
Menopause: final menstrual cycle
•Avg age: 51, premature: ≤40
Postmenopausal: after menopause
•most women live ½ life here
gonadotropins  irregular
length of follicular phase 
irregular menstrual cycles
Artificial Menopause
•permanent cessation of function due to
surgical removal of ovaries or radiation
•after menopause, no functional
follicles  no CL  low P
•adrenal glands produce remaining
•NO clinical use in diagnosis
GONADOTROPINS *BEST
•FSH and LH RISE (FSH >LH)
•measure FSH, LH, estradiol to help
diagnose menopause
*can measure FSH & LH with
estradiol (FSH and LH increase
because no negative feedback from
estrogen and progesterone)
Reproductive Changes:
•vagina: thin, atrophy, flat ruggae
•cervix: atrophy, small, less mucous
•uterus: atrophy, shrink
•oviducts: decrease in size
•ovaries: atrophy, smaller, less
hormones, no ovulation
•support: loss of tone, relaxation
Urinary: estrogen maintain epithelium of
bladder and urethra  atrophy
•atrophic cystitis: UTI sx
•lose urethral tone(urethral caruncle)

Menopaus About/Clinical Presentation Treatment

e
Atrophic Atrophic epithelium with flattened rugae
Vaginitis
•loss of lactobacillus which converts glucose to lactic
acid  increase in vaginal pH to 5-7
S/S:
•vaginal burning, soreness
•dyspareunia
•dryness or thin water or serious discharge
-early: diffuse or patchy red, +/- petechiae, flat ruggae
-late: smooth, shiny, pale
-friable: bleeding w/ minimal traum
-GU: urgency, frequency, dysuria, incontinence
DX: clinical *may do vaginal cytology to assist
About/Clinical Presentation
Hot MC AND CHARACTERISTIC SX
Flashes •alterations in cutaneous vasodilations, perspirations,
reductions in core temp, high HR
•heat or burning in face, neck, chest, back
- HA pressure  flush  sweat
•palpitations, weak, fatigue, faint, vertigo
duration: seconds-10min (avg 4 min)
frequency: 1-2/hr to 1-2x/wk
Initial Treatment:
•FIRST LINE: vaginal moisturizer
*improve symptoms but not atrophy
-Replens, vagisil, K-Y Liquibeads
-Lubricants with sexual activity
Water-based (Astroglide, K-Y),
Silicone-based (Pjur), Oil (Elegenace)
*caution with oil due to condom break
Mod/Severe: Topical Vaginal Estrogen
*even okay if she has a uterus
•restored pH and microflora, increased
vaginal secretions, thickened epithelium,
diminished overactive bladder, fewer UTIs
•systemically absorbed
Treatment (HOMRONAL)
Mainstay: ESTROGENS *transdermal 1st
-block sx and physiologic changes
-E/P combo: if can take E
-increase breast CA risk with P added
•Progestin alone: women cant take E
•Tibolone: synthetic steroid with E, P, A
•Bioidentical hormones: $$$$
-custom-made hormone
•SERM + Estrogen
Other options:
•Prasterone (vaginal DHEA): 6.5mg suppository
-converts androstenedione and T  estrone and estradiol
•Ospemifene (Osphena): SERM (mimics E) 60mg daily
-MC SE: hot flashes, mild endometrial thickening
•Testosterone: 1-2% cream is estrogen is CI
•Pelvic PT: refractory cases
•laser, vitamin, probiotics *mixed data about all of these
Overall: VAGINAL preferred over systemic
-cream: conjugated estrogen or estradiol
-rings: estradiol 7.5mcg releasing x3mo
-tablet: estradiol 4mcg, 10mcg
Treatment (Non-hormonal)
•SSRI/SNRI: *1st line who cant/don’t want HRT
-cautions with SSRI & Tamoxifen (esp Paroxetine)
-increased risk of breast CA or death
•Black Cohosh or Phytoestrogens
-can stimulate breast and uterine tissue
•Gabapentin: SE: sedation
•Clonidine: more effective than placebo (vasodilation)
•Weight loss, acupuncture, mind/body, vitamin E

Benefits Risks Main Treatment Other Options

HRT Known: •endometrial CA: hyperplasia within 1yr 1st line: transdermal (decrease SE) Other Forms:
•reduced SX (vasomotor, GU) -unopposed E  proliferation, hyperplasia, •0.625mg PO conjugated estrogen •Progesterone only: *better than SNRI
*vaginal estrogen is as efficaious as neoplasia; give Progesterone to decrease •increase dose at 1 month intervals depot MPA IM or po norethindrone
 oral or transderm for GU symptoms
•reduced risk of osteoporosis:
improves density, reduce fracture
*benefit from E
Possible
•improved skin collagen & thickness
•reduced UTI
•reduced falls
•reduced cataracts, osteoarthritis, DM
•reduced colon CA (combo therapy)
•reduced CHD (cholesterol clearance)
Lipids
lipids: lower LDL, higher HDL
but can increase TG
•breast CA: only in COMBO (due to P)
-risks: early menarche, late menopause
•thromboembolic: 2x w/ combo, 33% E only
-lower chance with transdermal
•stroke: increased risk in E only and combo
-lower incidence with transdermal v oral
•gallbladder disease: greater risk with E-only
Other Effects *menstrual cycle symptoms
•other: edema, bloat, mastodynia & breast
enlargement, PMS, HA, lots cervical mucus
CI:
•breast & E-dependent CA *endometrial,
undiagnosed abdominal vaginal bleeding
•thromboembolism, liver, hypersensivity
•pregnancy
Caution: gallbladder, cholestatic jaundice,
high TG, hypothyroid, flui with cardiac/renal,
hypocalcemia, endometriosis, hepatic
hemangioma
•must add PROGESTIN if patient
has an intact uterus (no E alone)
-medoxyprogesterone acetate(MPA)
-micronized P: lower risk of breast
cancer and CHD
Regimens:
NOT REC. for >3-4yr
Regimen One: *older method
•Estrogen on days 1-25
•progesterone days 14-25
•withhold both day 26-end of month
•light, painless period each month
Regimen Two: *most common
•daily E & P together w/o stop
•initial bleeding or spotting
•eventually: atrophic endometrium
Only use HRT for vaginal
atrophy and hot flashes
-more effective than SNRI
•Tissue Selective Estrogen Complex
SERM (Duavee or BZA/BE) + Estrogen
-agonist bone; antagonist endometrium
-neutral on breast
-lower risk breast & endometrial CA
SE: VTE, liver disease
•PO Estrogen + Levonorgestrel IUD
-avoid systemic effects of P but prevent
endometrial hyperplasisa and cancer
•SSRI: Citalopram, Escitalopram
-Paroxetine: caution with Tamoxifen
•SNRI: Venlafaxine, Desvenlafaxine
SE: insomnia
•Anticonvulsant: Gabapentin,
•Clonidine: helpful with comorbid HTN
and menospausal s/s
CAM: black cohosh, isflavones, Vit E,
exercise, weight loss, relaxation

INFECTIONS-chancroid, lymphogranuloma venecreum

Other About Presentation Diagnostic Treatment

Herpes •HSV type 2 or type 1
Genitalis •infection through intimate
contact
•periods of viral shedding
without sx may occur
•vesicles that become painful erosions or ulcers
surrounded by an erythematous halo
Prodrome: itching, burning, flu-like symptoms
+/- inguinal lymphadenopathy
+/- urinary symptoms (dysuria, urinary retention)
•viral culture, PCR, DFA, Tzanck
Antiviral therapy x7-10days
•Valcyclovir, Acyclovir
Recurrent: Antivirals x1-5 days
Prophylaxis: re-evaluate periodic
Prevention: contraception, antiviral

Condyloma •HPV type 6 and 11
Acuminatum
•prevented to some extent
by vaccination with quad
HPV vaccine (Gardisil) or
9-valent HPV vaccine
(Gardasil 9)
•white exophytix or papullomatous growth •mucous membrance, extensive on labia Provider:
PERFORM PAP & COLPOSCOPY •topical application of bichloracetic
•coalese and form large cauliflower masses, flat acid, tichloracetitic acid,
podophyllin, cryoptherapy
•may also see flat lesions with granular surfaces
•can affect vagina, cervix, vulva, perineum, Patient: topical application of
perianal areas pdofilox or imiquimob
Syphillis Bugs: •Primary: lone painless ulcer (chancre) 1st line: PCN (even if prego)
Treponema pallidum •Secondary: generalized rash, malaise, fever •primary/secondary, <1yr: 1 dose
•Latent: asymptomatic with positive serology •latent, tertiary, >1y: 3 weeks
•Tertiary: systemic involvement (cardiac, neuro) 2nd line: Doxycycline
primary v secondary

OBGYN About Clinical Presentation Diagnostics Treatment

PID and •MC serious infection occurring Clinical Features Labs: empiric treatment for PID:
Tubo- in reproductive-aged women •lower abdominal pain •pregnancy test *r/o ectopic •sexually active women or other women at risk for
Ovarian •occurs when infection ascends •vaginal discharge & bleed, dyspareunia, •wet prep, swab for G/C STDS if they have pelvic pain + no other cause
Abscess from the lower genital tract urinary discomfort, fever, N/V •CBC, ESR, CRP for illness, plus ONE:
•peritoneal symptoms or minimal sx •pelvic US -cervical motion, uterine, or adnexal tenderness
•MCC: Neisseria gonorrhea, •RUQ pain with jaundice
Chlamydia trachomatis (MC)  Fitz-Hugh Curtis Admission criteria Inpatient Treatment options
•failure to respond to outpt tx •Cefotetan or Cefoxitin + Doxy
Risks: pelvic exam: •pregnancy and adolescents •Clindamycin + Gentamicin
•multiple partners, STDs •uterine, adnexal tenderness and/or *adolescents risky because Alternative: Augmentin + Doxycycline
•sexual abuse cervical motion tenderness transformation zone on cervix
•IUD “Chanelier sign” •toxic Oral and Outpaitent Regiments
•douching •cant tolerate oral •Ceftriaxone + Doxy +/- Flagyl
•substance abuse •cant exclude other dx •Cefoxitin + Doxy +/- Flagyl
•adolescents •3rd gen ceph + Doxy +/- Flagyl

OBGYN About Clinical Presentation Diagnostic Treatment

Candidal Bug: Candida albicans
Vulvovaginitis
Risks: DM, HIV, obese, prego,
ABX, steroids, OCPs
•intense vulvar pruritus
•thick, white cottage cheese discharge
•minimal odor
•vulvar erythema, edema
•burning sensation after peeing
•Vaginal pH: elevated 4-5
•saline prep: 1 drop discharge: 1 NS
-branching filaments,pseudohyphage
•KOH: 1 drop 10% KOH
-dissolves epithelial cells & debris
•Culture: GOLD STANDARD
Pharm: 1-3d topical, 1d Fluconazole
•topical or oral antifungals
•boric acid or gentian violet
Complicated:
•4+ episodes/yr, severe symptoms, non-
albicans, uncontrolled DM, HIV,
steroid, pregnancy
-2 doses of fluconazole

Bacterial •overgrowth of abnormal flora •copious, thin, homogenous, gray-white •pH: elevated 5.5-7 (ELEVATED) •Metronidazole (Flagyl) x7d
Vaginosis •decreased lactobacillus vaginal discharge •Clindamycin (Cleocin) x3-7d
*NOT STI •itching, burning, dyspareunia •saline prep: “Clue Cells” •Tinidazoel (Tindamax) x3-7d
Bug: Gardnerella vaginilis *worse after unprotected sex •KOH: (+) “whiff test” fishy odor
•“fishy” smell, enhanced after KOH prep Prevention: probiotics, acid douche

Trichomonal •unicellular flagellate protozoan
Vaginitis
•MC non-viral STD in US
•perinatal complications,
increased HIV transmission
Exam: no mucosal inflammation
•profuse extremely frothy, greenish, at
times foul-smelling vaginal discharge
•erythema, petechial: strawberry cervix
•pH: elevated 5-5.5 (ELEVATED)
•saline prep: motile trichomonads
•nucleic acid: 45 minutes
•pap smears, culture
•Metronidazole or Tinidazole x1dose
-or Metronidazole 500mg BID x7d
Resistant: Tinidazole 500 TID x 7d
•treat partner & screen for other STIs

Gonorrheal •MC infects glands of cervix, •80-85% of women asymptomatic •nuclei probe or culture of discharge •single IM Ceftriaxone 250mg
urethra, vulva, perineum, anus •copious mucopurulent discharge possible -gram (-) diplococci •Chlamydia TX: Azithromcyin 1g

Chlamydial •may see mucopurulent cervicitis, •culture, immunoassay, nucleic acid •Azithromcyin 1g po once
dysuria, and/or postcoital bleed •can be found on pap smear •Doxycyline 100mg po DIB x 7 days
•treat partner

OBGYN About MOA SE/DDI

Vaginal •less systemic risk; rapid relief •inhibit enzyme for membrane synthesis SE: burn, itch, swell, rash, discharge
Antifungal •weaken latex (caution) •Nystatin: increase permeability of wall
DDI: rarely Warfarin
Oral •higher systemic risk •inhibits enzyme for cell membrane synthesis SE: GI, abd pain, dizzy, HA, drowsy, allergy
Antifungal •delayed relief
(Fluconazole) •can NOT use in 1st T prego DDI: erythro, clopidogrel, warfarin, theophylline, sulfonylureas,
thiazides, rifampin, cimetidine *avoid with hepatotoxic drugs

Nitromidazole bind to and deactivates enzymes SE: dizziness, HA, false lab results •alcohol (3d), Disfulfiram (2 wks), anticaogulatns, phenytoin,
-GU: dark colored urine, irritation lithium
-GI: pain, upset, dry mouth, glossitis, altered taste
-Rare: neurotoxic, anaphylaxis, SS

Clindamycin Binds to ribosomes blocking protein SE: C. diff, local irritation, abd pain, GI, latered tast •macrolides, neuromuscular drugs, antiperistaltis drugs
synthesis Rare: blood dyscrasis, hepatotoxic, anaphylaxis

NEOPLASMS

Breast CA About Presentation Diagnostics Treatment

Pagets •Eczematoid eruption •pain, itching, burning •Full-thickness biopsy of lesion •MASTECTOMY
Disease and ulceration •erosion, ulceration •Insitu: no lymph biopsy
•may see bloody nipple discharge •Invasive: biopsy lymph •May try excision of nipple,
•Arises from NIPPLE •retracted nipple areola, local mass
can spread to areola
•palpable mass: 50% (9% invasive cancer)

•no palpable mass: noninvasive cancer or ductal carcinoma

Inflamamtory •Aggressive but rare •Diffuse, brawny edema of skin with erysipeloid border •Suspected mastitis does not rapidly •Chemo  surgery and
Carcinoma •blocked dermal lymphatics by tumor emboli response (1-2wk to ABX  biopsy radiation
•“Peau d orange” (orange peel) skin
 •usually NO palpable mass

Medication and Usage MOA Side Effects DDI

SERM •Tamoxifen (Nolvadex) •binds to estrogen receptors
•Raloxifene (Evista) •block estrogen activity in some
•Toremifene (Fareston)
•tamoxifen - blocks in breasts;
•Used for treatment of breast CA and mimics in uterus, bone
chemoprevention of breast CA in •toremifene - blocks in breasts;
some high-risk women mimics in uterus, bone
•raloxifene - blocks in breasts,
uterus; mimics in bone
Common •Not for use with other hormone-
hot flashes, nausea, muscle aches and modulating anti-CA therapy
cramps, hair thinning, headache,
paresthesias •SSRIs, cimetidine can reduce efficacy
Benefits: improve bone & lpids •Avoid with QT-prolonging agents
Risks: thrombosis, fatty liver,
endometrial cancer, false thyroid

Aromatase •anastrazole (Arimidex) •inhibit aromatase (enzyme that Common: •Caution when using with, or do not use
Inhibitors •exemestane (Aromasin) blocks conversion of testosterone hot flashes, GI upset, muscle with, other hormone-modulating anti-CA
•letrozole (Femara) *induce ovulation to estrogen) weakness, joint pain, headache, therapy
worsened ischemic heart disease
•Used for treatment of breast CA •May increase serum concentration of
Risks: methadone or L-methadone
•May be used alone, in combination •Hypercholesterolemia
with GnRH blockers, or •Insomnia, impaired cognition, •Do not use with estrogen or
before/following SERMs fatigue, mood changes, Thinning hair immunomodulating drugs

CI: pregnancy

Fulvestrant •used for metastatic breast cancer •GnRH agonists/antagonists •Used to reduce release of GnRH and
(Faslodex) •attaches to and causes destruction of FSH/LH
estrogen receptors
•does not mimic effects of estrogen

Breast CA About Clinical Presentation Diagnostics Management

Breast CA •MCC of non-skin cancer
in women
•2nd MCC cancer death in
women (after lung CA)
Risks:
•personal history
•(+) FHX:
-1st degree relative: 2x risk
-2nd degree relative: 3x risk
•Genes: BRCA1 & BRCA 2
*most arise from intermediate ducts and are Mammography: women >40 Hormone Receptor Sites
invasive *can detect cancer as early as 2 years •ER (+) tumor: slightly lower
•microcalcifications & speculated liklihood of early recurrence
Types: •Most diagnosed after abnormal test •Er (-): mets to liver, lung, brain
•infiltrative ductal carcinoma (MC) *higher chance of recurrence
-lymphatic metastases Ultrasound: women <40
•infiltrative lobular carcinoma (+) ER:
•pagest disease MRI: rapid uptake of contrast •Anastrozole (postmenopausal)
•inflammatory •Tamoxifen (premenopausal)
Biopsy: *prevention in high risk family history
Clinical Presentation •FNA: removes the least amount of tissue, •Trastuzuma (anti-HER2)
•painless breast mass *>5cm suspicious but will not allow for receptor testing
 -BRCA 1: higher risk
-BRCA 2: lower risk
•Nulliparity
•First full-term pregnancy
>30
•Early menarche (before 12)
•Late menopause (after 50)
•increasing age
•Postmenopasual HRT
•Hx uterine CA
•hard, fixed, irregular margins, nonmibile
•upper outer quadrant
*due to more tissue in that area
Exam:
•skin changes: erythema, discoloration,
ulceration, skin retraction (Coopers
ligament), bloody discharge
•Palpation of regional lymph nodes: axillary,
pectoral, supraclavicular, infraclavicular,
subscapular, epitrochlear and lateral chain
•axillary lymphadenopathy
•mets: bone, lungs, liver, brain
•Core Biopsy: takes more tissue, but
allows for receptor testing
•Open Biopsy: MOST ACCURATE
Genetic Testing
•considered for members of high risk fhx
•genetic counseling needed before and after
Screening:
Mammogram every 1-2yrs women 50-69
•ACS:
CBE q3yrs 20-39, mammo + CBE age 40
•ACOG:
CBE + mammo q1-2yr 40-50, yearly 50+
•USPSTF:
mammo +/- CBE q1-2 yrs, age 50-74
Radiation: usually done after
lumpectomy or mastectomy
Surgery:
Radical mastectomy:
•removal of breast, pectoral muscles,
axillary lymph nodes
Modified radial mastectomy:
•removal of breast and underlying
pectoralis major fascia
Breast Conservation: excise tumor
with negative margins, lymph biopsy
•stage I & II and some III
Follow-Up:
•Close follow-up needed due to high
risk of recurrences
•exam Q 4 mo x 2 yrs, then Q 6 mo x
3 yrs, then yearly
•Mammogram 6 mo after radiation
then becomes yearly

Timing Breast Exam Pelvic Exam History

Well First Reproductive Health (Age 13-15)
Woman •age-appropriate reproductive health info
Exam •no pelvic exam unless symptomatic or
STD screen needed
Pelvic and Pap Smear (Age 21)
•do NOT need pap in asymptomatic
patient <21yo even if sexually active
•pelvic exam: annually
•pap smear: varies on findings
•do not need to do pelvic before
prescribing birth control
•Expose patients breasts one at a time to Traditional Method
reduce embarrassment Step 1:
•obtain cervical scraping from
•Inspect in all four positions complete squamocolumnar
- Sit up right junction by rotating 360 degree
- Hands on hips
- Leaning forward Step 2:
- Lying down •saline-soaked cotton swab or
small brush into the endocervical
•Palpate all 4 quadrants & Tail of Spence canal and rotate 360 degrees
•Palpate for regional LAN
New Method: ThinPrep Test-
Bimanual
•compress uterus and adnexa
•Cervix: 3-4cm diameter and moderately
firm, mobile, without undue discomfort
Rectovaginal
•Insert well-lubricated middle finger into
rectum and index finger into vagina
•raise cervix toward anterior abdominal
wall and palpate uterosacral ligaments

Clinical Breast Exam (CBE)
•every 1-3 years for women 20-39 years
old
•yearly and mammograms in 40+
•do NOT take place of mammogram
Comprehensive Skin Exam
Routine •USPTF: no recommendation
Screening
•ACS: every 3 years for pts 20-
40 and yearly 40+ (
•UV Protection: SPF 15+
Risks:
•suspicious moles or lesions
•hx skin CA (personal or fhx)
•atypical moles
•hx extensive sun exposure
•50+ total moles
OBGYN Risks
Cervical Risk Factors:
Dysplasia/ Sexual Activity Factors:
Cancer •multiple sexual partners
•early onset of sexual activity
•high-risk sexual partner
Infection Factors:
•HPV infection (BIG ONE!)
•History of sexually transmitted
infection
•Immunosuppression (HIV)
•SBE no longer recommended spatula/brush/broom
•Fecal occult blood test
False readings:
•wrong type of lubricant: False readings:
interfere with cell prep •obesity
•infections: BV, G/C •uncomfortable, rigid, guarding
•not getting a good cell sample
Pap Smear Screening STD Screening High Risk Breast/Colon
•Start cervical CA screening at age 21 Pregnant Women: •Young (15-24) Mammogram+/- CBE
•Ages 21-29: pap every 3 years •Hep B, HIB, Syphillis: ALL •African American ACS, ACOG, AMA:
•G/C: <25yo or high risk •Unmarried -Yearly age 40
•Ages 30-65: Pap + HPV every 5 years •Hep C: high risk •Low socioeconomic
or pap every 3 years •New partners in past 60 USPSTF, WHO:
Nonpregnant Women: days -Biennial at age 50
•Age >65: stop screening if… •ALL sexually active women •Mult. partners -Discontinue after 74yo
-no hx of moderate/severe should receive HIV, G/C yrly •HX STI
dysplasia or cancer AND 3 (-) paps •Illicit drugs Colon:
in a row or 2 (-) PAP +HPV results •high risk: HIV, HSV, •Admission to Low risk:
in a row in past 10 yrs syphilis, trichomoniasis, correctional •Yearly at 50+ or sDNA
Hepatitis B & C •Internet partner every 3 years
•Sex workers
•Don’t screen sexually active High risk: refer
women 25+ if not high risk •D/C after 75
HPV Dysplasia Cancerous
HPV & Cervical Dysplasia: CIN I: mild cervical dysplasia Bethesda System
•HPV present in >80% of all CIN •LOWER 1/3 of epithelial lining
•HPV 16: 50-70% HPV 18: 7-20% Atypical Squamous Cell (ASC-US/H)
*cigarettes have a synergistic effect CIN II: moderate cervical dysplasia •undetermined significance, cannot
with HPV  cancer •LOWER 2/3 of epithelial lining exclude high grade lesion
High Risk: 16, 18, 31, 33, 35, 39, 45, CIN III: severe cervical dysplasia Low-Grade Squamous
51, 52, 56, 58, 59, 68 •over 2/3 of epithelial lining; FULL Intraepithelial Lesion (LGSIL/LSIL)
thickness  corresponds to CIN-1
•High-risk HPV test performed after
abnormal Pap High-Grade Squamous
•Most + do NOT develop CIN or CA ALWAYS treat CIN II and III except: Intraepithelial Lesion (HGSIL/HSIL)
 Others:
•multiparity Vaccines: Gardasil 9
•long term OCP use (6, 11, 16, 18, 31, 33, 45, 52, 58)
•female: age 11-26, male: age 11-21
•<15yo: 2 doses, 6 months apart
•>15yo: 0, 2, 6 months
*min interval b/w 1st and 2nd 4
weeks, b/w 2nd and 3rd is 12 weeks
•pregnant woman (wait till postpartum)  corresponds to CIN II and III
•CIN II in adolescents (high chance of  excision (LEEP) or ablation
spontaneous regression)
Atypical Glandular Cells (AGC)
Glandular cells: normal components of
the endocervix  secrete mucus
Atypical: dont match normal glandular
cells but are not definitely cancer

Pap Smears Atypical Screening Colposcopy After Colposcopy

•21-29yo: every 3 years
•30+: HPV + pap q5y or pap only q3y
•30+/+HPV: pap&HPV 1yr or genotype
•>65: stop if no hx dysplasia or CA, 3 (-)
paps or 2 (-) pap + HPV in a row in last
10 years
3 options:
1. repeat serial cytology: every 6
months until 2 consecutives normal
-second abnormal  colposcopy
2. High-risk HPV: colposcopy if +
3. Immediate referral to colposcopy
Before repeat, treat the underlying:
•hormones if atrophic vaginitis
•antimicrobials for infections
LSIL, HSIL, ASC-H, AGC 
Colposcopy
Illuminated low-power magnification CIN I: expectant
-3-5% aqueous acetic acid solution •high chance of regression
-directed biopsies of abnormal areas •2 paps every 2 months or…
-curette or brush of endocervical canal Pap + HPV at 6 months
•repeat if abnormal cytology or HPV+
Indications: •if all normal, then routine screening
•abnormal cytology or HPV test
•clinically abnormal cervix Surgery:
•unexplained intermenstrual or •CIN II/III
postcoital bleed •Invasive Cancer
•vulvar or vaginal neoplasia •Otherwise abnormal or unsatisfactory
•history of in utero DES exposure colposcopy

Cryotherapy: office procedure: nitrous oxide or carbon dioxide over ENTIRE lesion
- pros: easy to use, low cost, low risk; cons: f/u colposcopy can be unsatisfactory
- SE: cramping, copious watery discharge for week
Carbon Dioxide Laser: destroys tiuuse with narrow zone, depth of 7mm
- Pros: precise, in office or outpatient hospital; cons: local anesthesia, expensive, training
- SE: pain, discharge, bleeding
Loop Electrosurgical Excision Procedure (LEEP): small fine wiare loop attached to electrosurgical generator *CIN II and III
- Pros: easy to use, tissue histology, in office with local; cons: increased risk premature delivery in pregnancy
- SE: cramping, bleeding (1 week), discharge (3 weeks)
Cold Knife Conization: excision of cone-shaped postion of cerix with scalpel
- Pros: histology; cons: expensive, done in OR, increaserd risk premature delivery
- SE: cramping, bleeding, discharge
OBGYN About Clinical Presentation Diagnostics Management
Cervical Types: •asymptomatic in early stages •colposcopy with biopsy Carcinoma in situ (stage 0)
Cancer •squamous cell (MC!) •excision (LEEP, cold knife)
•adenocarcinoma •post-coital bleeding or spotting CIS or pap abnormal: conization •ablation (cryotherapy, laser)
•clear cell (linked with DES) •irregular, heavy vaginal bleeding or watery •total abdominal hysterectomy +
discharge bilateral salpingo-oophorectomy
Spread: •weakness, weight loss, anemia, pelic pain
•paracervical nodes (MC) *late symtoms Stage 1A: total hysterectomy or radical
•parametrial, obturator,
hypogastric, external iliac, sacral Stage 1A2, 1B, IIA:
Exam: cervical discharge or ulceration •radiaction with brachytherapy
Risks: •early: cervix normal •radical hysterectomy with bilateral
•HPV (16, 18, 31,33) •late: enlarged, irregular, firm pelvic lymphadenectomy
 •early sexual activity, STIs
•lots of sexual partners
•smoking, DES expsore
•cervical intraepithelial neoplasia
•immunosuppression
OBGYN About
Ovarian Types:
Cancer Epithelial ovarian cells (MC!!!)
•repeated epithelial trauma/repair
•near menopause
•serous cystoadenocarcinomas
•assocciated with CA-125
Germ cell tumors: 20-30yo
•AFP, hCG, LDH
Sex Cord Stromal Tumors
•estrogen & andogrens
•granulosa cell tumors (inhibin)
Risks:
•(+) FHX (strongest risk)
•increased age, white
•early menarche, late menopause
•endometriosis, nulliparity
•smoking, obesity, talcum powder
REDUCE RISK
•OCPs, progesterone therapy
•breastfeeding, tubal ligation,
hysterectomy/salpingectomy
Neoplasms About
Preinvasiv •vulvar intraepithelial neoplasia (VIN)
e Vulvar associated with multifocal lower
Disease genital tract disease
-younger: VIN MC, median age: 40yo
Risks: HPV, HIV, smoking
Pagets •Intraepithelial neoplasia of vulva
Disease (adenocarcinoma in situ)
• mostly confined to epithelium
-perirectal, butt, thigh, inguinal
Cervix
Endophytic: barrel-shaped
Exophytic: friable, bleeding, cauliflower
Clinical Presentation
Early: poorly defined or vague
•GI: bloating, abdominopelvic pain,
early satiety, indigestion
•GU: frequency, urgency, dyspareunia
•Other: fatigue, back pain
Late:
•early symptoms
•increased abdominal girth (ascites)
•nausea, anorexia
•dyspnea (pleural effusions)
Exam:
•solid, fixed irregular adnexal mass
•unilateral cystic masses
•abdominal distention, upper abd mass
•lymphadenopathy: sister mary joseph
*mets to umbilical lymph nodes
Presentation
•white, hyperkeratotic papules
•vary in color-white to velvety red or black
•MC SYMPTOM: pruritis
MC: pruritis, vulvar soreness
•pruritic, slow spread, velvety-red
•”Red Velvet Cake”
•eventually becomes eczematoid with
maceration and development of white plaques
Diagnostics
Genes:
Breast-Ovarian Cancer Syndrome
•BRCA 1 & BRCA 2
•MC in women of Ashkenazi Jews,
French Canadian, Icelandic
Hereditary Nonpolyposis Colorectal
Cancer Syndrome: high risk of
colon, breast, endometrial CA
CA-125: elevated in 50%
•useful in postmenopausal but not
premenopausal women
•normal does NOT exclude CA
•younger pts: AFP, LDH, hCG
HE4: similar sensitivity to CA-125
Pelvis US: solid, septation, ascites
•delineate benign or malignant
*INITIAL TEST
CT or MRI: characterize details
Biopsy: DEFINITIVE DX
Diagnostic
colposcopy with biopsy
•suspicious lesions
 GOLD STANDARD
Vulvar Biopsy
Locally advanced (IIB, III, IIVA):
•radiation + chemo
Advanced: radiacation, chemo
Management
EOC CANCERS
Surgical: required unless pt cannot tolerate
•definitive diagnosis and staging
•removal of tumor and contralateral adnexa;
often hysterectomy & infracolonic
omentectomy
Medical: Chemo 4-6wk post-surgery
USE CA-125 TO MONITOR PROGRESS
•prophylactic bilateral salpingo-
oophorectomy in women with genetic
predisposition *better to do by age 35
GERM CELL CANCERS
Surgical:
•diagnosed at earlier stage then EOC
•removal of involved adnexa
Medical: curable in most cases
•chemo and radiation can be helpful
Treatment
Treatment based on biopsy
•wide local excision, laser ablation
•topical 5-FU, Imiquimob
•superficail vulvectomy
Follow-up: pelvic exam with colposcopy
q3-4mo until pt is disease free for 2 years
•Wide local excision + vulvectomy
Prognosis: high chance for recurrence
(-) node mets: good prognosis
(+) node mets: almost always fatal
Vuvlar Types: •vulvar pruritis and/or mass •remove all tumor wherever possible
Cancer •90% squamous cell carcinomas •bleeding or vulvar pain •wide radical local excision with inguinal
•2nd MC: malignant melanoma •mass on exam lymph node excision

•1/3 are midline or bilateral vulva
SCC: arise in labia MC
Risks:
•poor and elderly, infrequent exam
•HPV 16 & 18 (younger)
•chronic inflammation (older)
Exam: •pelvic exenteration: anus, rectum,
•red, white ulcerative or raised crusted lesion rectovaginal septum, urethra or bladder
•large, exophytic, cauli-flower like to small
ulcers to elevated red velvety tumor  •chemo: depends on CA extent and type
necrosis
Follow-up: every 3 mo for 2 years
•80% recurrences in 2 years

Neoplasms About Presentation Diagnostic Treatment

Preinvasiv •vaginal intraepithelial neoplasia (VAIN)
e Vaginal •single, or multifocal (MC)
Disease •MC in upper 1/3 vagina
•hx similar to cervical neoplasia (CIN)
-possible treated for CIN VIN
-smoking & HPV increases risk
Vaginal •VERY RARE
Cancer •cervix is uninvolved or minially
•MC form of vaginal malignancy is
extension of cervical cancer
*secondary tumor
Types:
•SQUAMOUS CELL: posterior upper
1/3 of vagina
•adenicarcinoma: younger patients
•sarcoma: highly aggressive in infancy
•melanoma
•abnormal cytology or as a visible lesion
•condylomatous lesions usually
associated with dysplasia
•lesions usually on vaginal ridges, may
be raised and have spicules
•Postmenopausal, postcoital bleeding
•may see discharge, mass, urinary sx
•MC site: labia majora, labia minora
Exam: red or white ulcerative or raised
crusted lesion
Sarcoma
•polypod, edematous “grape-like”
masses at vaginal introitus
Colposcopy and biopsy
-3-5% acetic acid solution
•colposcopy
biopsy: acetic acid or toluidine blue
application may help
VAIN I: regress, do not require tx
VAIN II/III: surgical excision or
carbon dioxide laser *may use 5-FU
•if extends to upper 1/3 vagina, can be
removed at time of hysterectomy
•monitor every 5-6 months
•hysterectomy, vaginectomy,
lymphadenectomy
-local invasion: pelvic exenteration
•melanoma is aggressive and do not
respond well to therapy
5-year survival:
•77% stage I
•45% stage II
•31% stage III
•18% stage IV

Risk: smoke, HPV, mult. partner, DES

OBGYN About Clinical Presentation Diagnostics Treatment

Endometrial •endometrial gland proliferation with •abnormal uterine bleeding TVUS: thickened endometrial stripe >4mm Hyperplasia WITHOUT Atypia
Hyperplasia cytologic atypia (menorrhagia, metrorrhagia, •Progestin (oral or IUD)
•precurose to endometrial cancer postmenopausal bleeding) Endometrial Biopsy: DEFINITIVE •repeat biopsy in 3-6 months
•if >35yo, increased endometrial stripe,
Risks: unopposed E, Tamoxifen, persistent bleeding Hyperplasia WITH Atypia:
•prolonged unopposed estrogen with thick stripe •total abdominal hysterectomy
•chronic anovulation
 •estrogen only therapy
•PCOS, obsess, perimenopause
•early menarche, late menopause
•Tamoxifen, lymch syndrome
Endometrial •MC GYN malignancy
Cancer •MC in postmenopausal
•estrogen-dependent cancer
*estrogen stimulate endometrium
Types:
•adenocarcinoma (MC)
•serous *older patients, poor prognosis
•clear cell *aggressive
Risks: high estrogen exposure, obese,
PCOS, E-only HRT, Tamoxifen, DM
BREAST DISORDERS
Female Breast
Breast •Secondary reproductive gland
-arises from ectoderm
components
•glands & ducts organized into lobes
•stroma (fibrous tissue) to bind lobes
•abnormal uterine bleeding
(postmenopausal bleeding!)
•abnormal vaginal discharge
•lower abd cramps
Reduce Risk:
•COCs, smoking
•Each breast: 12-20 lobes base: near ribs
•Apex: contain major excretory duct for
the lobe *closer to the nipple
•Each lobe: group of lobules “pedal” w/
TVUS: thickened endometrial stripe >4mm
Endometrial Biopsy: DEFINITIVE
*D&C more definitive due to larger tissue
sample
•CA-125 elevated in 20% of stage I
•80-85% of normal breast: adipose
•nonpregnant/nonlactating: small,
tightly packed alveoli
•pregnant: alveoli hypertrophy and
Stage I: total abdominal
hysterectomy
*younger, more favorable
Stage II-III: TAH-BSO + lymph
*older, poorer prognosis
StageIV: systemic chemo
Lymph Drainage
•dermal, subderma, interlobar, and
prepectoral systems
•MOST drain into axillary nodes
-receive most lypmphatic drainage \
therefor are MC site of breast
cancer mets *Sentinel nodes
 •Adipose tissue within/between lobes several ducts which unite to form the
major duct for the lobe “flower”
-each major duct widens to form
ampulla then narrows as its ind.
opening in the nipple
-usually only 6-8 opening visible on
nipple surface
-areola also contains sebaceous
glands (Montgomery glands) which
may be visible punctuate priminences
lining cells proliferate
Alternate pathway: internal mammary,
•lactation: alveolar walls secrete supraclavicular, epitrochlear,
lipids and proteins (milk) contralateral axillary and abdominal
lymph nodes
•Deep surface of breast lies on fascia
that covers the chest wall muscles
-fascia is condensed into
multiple bands (coops ligaments)
support breast in upright position

Female Breast Puberty and Breast Menopausal and Postmenopausal Pregnancy

Breast •Fetal and Prepubertal Breast
Development
and •Fetal: primordial breast arises from
Physiology basal layer of epidermis
•Prepubertal: rudimentary bud
-few branching ducts
-ducts are capped with alveola
buds, end buds, or small lobules
Lactation Changes:
•rapid drop in E and P postpartum
•breasts fully mature and secrete milk
-drop in P triggers milk production
-prolactin is main regulator of
milk production
•after nursing ceases or if estrogens
are given, breast rapidly returns to
pre-pregnancy state
-decreased cellular elements and
increased adipose tissue
•Age 10-13: E/P effect breast tissue
-communication between epithelial and
mesenchymal cells
-extensive branching of ductal system
and lobule development
•Overall growth: increased acinar tissue,
ductal size & branch, adipose deposits
•Nipple & areola enlarge w/ puberty
-smooth muscle fibers surround base of
nipple
-nipples sensitivity to touch increases
Premenstrual: breast epithelial cells
proliferate during the luteal phase when
E & P are increased
-acinar cells increase in # and size
-ductal lumens widen
-overall increase breast size and
turgor
-frequently see observable increase in
breast fullness and tenderness
*1 week before menses
Menopausal changes
•decrease in estrogen and progesterone
•Breast will atrophy and involution
-Low # and size of ducts & acini
-Eventually regress to almonst
infantile state (breast tissue, but still
have adipose)
-Adipose tissue may or may not
atrophy
-Parenchymal elements lost (functional
tissue)
Postmenopausal: breast epithelial cells
undergo programmed cell death at the
end of the luteal phase when E and P
levels decline
-decreased size and turgor
-reduced number and size of breath
acini
-decreased diameter of ducts
*cyclic menstrual breast changes are
very variable
Pregnancy Changes
•final breast tissue differentiation
occurs under the influence of
progesterone and prolacting and
is NOT complete until first full-
term pregnancy
•marked increase in breast size
and turgidity
•deepening pigmentation of the
nipple-areola complex
•nipple enlargement
•areolar widening with increased
number and size of lubricating
glands
•branching and widening of breast
ducts
•increased acini
Late pregnancy: fatty tissue are
almost completely replaced by
cellular breast parenchyma

OBGYN About Presentation Treatment Congestive Mastitis

Mastitis •seen with lactation and nursing
•typically primigravida nursing
patients *1st pregnancy
•rare prior to 5th day postpartum
Bug: S. aureus
•RARE if patient is not nursing
Classic:
•painful erythematous lobule in outer
quadrant of breast noted during 2nd
or 3rd week of puerperium
•unilateral breast pain, tenderness,
warmth, swelling, induration
•cracked nipples or fissures
•Antibody-coated bacteria in milk supports
diagnosis *look under microscopy
Treatment
•avoid milk stasis  continue breastfeeding
*wont hurt baby to feed
•local heat warm compresses, well-fit bra
•instruct on proper breastfeeding techniques
•bilateral breast enlargement 2-3
days postpartum due to milk stasis
Clinical Presentation:
•bilateral breast pain and swelling
Management:
•drainage (manually or pump)
 and no other cause (radiation) •ABX x10-14d •if do not want to breastfeed: ice
•Abscess: pitting edema and fluctuation -Dicloxacillin, Naficillin, Augmentin pack, tight-fitting bras, analgesics,
-Cephalexin, Clinda, Erytho, Bactrim drainage
-Severe: inpatient IV with Vanc or Clinda

Breast •MC in lactating, primigravida •May arise from pre-existing mastitis Non-peirpheral: peripheral, subareola; I&D with ABX
Abscess •red, mass, pain, fluctuance, Peripheral: skin infection
Bug: S. aureus induration Subareola: due to keratin-plugged milk ducts
behind nipple *multiple abscesses

OBGYN About Clinical Presentation Diagnostics Treatment

Fibrocystic •MCC cyclic breast pain in
breast reproductive age women
Chnges •MC age 30-50 years
(Glandular
Hyperplasia) *stop after menopause unless HRT
Pathophysiology:
•hormonal imbalance that may
produce asymptomatic breast lumps
•estrogen considered factor
•possible increase if drink alcohol
•caffeine can worsen pain
•Mass with pain or tenderness
•pain secondary to proliferation of
normal glandular tissue
*can increase and decrease size
•usually present or worse
during premenstrual phase (prior to
menstruation)
Exam:
•multiple, nodular, mobile, smooth
round lumps in both brests
•estrogen stimulates ducts,
progesterone stimulates stroma
•US or mammogram •reassurance of benign findings
*no mammogram if •avoidance of trauma, well-fitting, supportive bra
<30yo •abstaining from caffeine, coffe, chocolate
•OCPs can reduce symptoms
FNA:
•straw colored or •CAM: evening primrose oil, vit E 400U
green fluid •OTC analgesics: Tyneol, Ibuprofen
(no blood) •severe pain: Danazol, Tamoxifen
•Refractory: surgery
Prognosis: exacerbation may occur until menopause

Fibro- •Common, benign solid tumor
adenoma •focal abnormality of breast lobule
•young women
•more frequent and earlier age of
onset in black women
Pathophysiology:
•suspected possible hormonal link
•increased in size during pregnany
and with estrogen therapy
•decrease in size after menopause
•Round, firm, discrete, mobile, non-
tender mass
•may enlarge with pregnancy
•does not change throughout cycle
•clinical •May be confused with Phyllodes tumor: a
fibroepithelial tumor that clinically resemble
US: solid, well- fibroadenomas and has a small chance of malignancy
circumcised,  surgical excision
avascular mass
Unclear diagnosis or rapid growth: surgery
Core Biopsy: •excision with margin of normal tissue
DEFINITIVE
Asymptomatic: monitor, core needle biopsy to confirm
OR repeat US and breast exam in 3-6 months

LABOR AND DELIVERY COMPLICATIONS- preterm labor

About Presentation Complications Management

Shoulder •failure of shoulder to spontaneously travers •turtle neck sign Maternal Complications: Nonmanipulative:
Dytocia the pelvis after delivery of the fetal head retraction of babys •perineal or vaginal tears •Mcroberts Manuever: hyperflexion and
due to impaction head: or red, puffy face •postpartum hemorrhage abduction of mothers hips
•anterior shoulder stuck behind pubic bone •uterine rupture
Manipulative: delivery of posterior arm
 Risks: Fetal Complications:
•macrosomic infants of diabetics •brachial plexus injuries: erbs palsy, klumpke
•post-term pregnancy, prolonged 2nd stage paralysis, cerebral palsy
•multiparity •erb-duchenne palsy: C5-C6  “waiters tip”
•forceps during delivery deformity (arm adducted, elbow extended,
•maternal obesity, advanced age forearm pronated, wrist flexed, finger curles)
•epidural anesthesia •fracture: clavicular, long bone
•anoxic brain injury, death
•woods corkscrew maneuver: rotation of
fetal shoulder 180 degrees
Others:
•gaskin four maneuver
•zavanelli maneuver: pushing head back in

Breech •presenting part is the buttocks and/or feet Exam: Complications: •external cephalic version before labor if
soft mass instead of •developmental dysplasia of hip successful; C-section is unsuccessful
Types: normal hard surface of •torticollis
•Frank: hips flexed, knees extended the skull •mild deformation •planned C-section
•Complete: hips and knees flexed
•Incomplete: one or both hips not US: confirm diagnosis •tral of labor and vaginal breech birth for
ocmpeltely flexed if uncertain low risk of complications

Umbiclical •cord extends past the presenting part of the •sudden, severe Risks: EMERGENCT C-SECTION
Prolapse fetus and protrudes into the vagina proonged fetal •low birth weight, premature, malpresentation
bradycardia or •long umbilical cord
•can cause low fetal O2 due to umbilical variable deceleration •pelvic deformities
artery vasospasm or vein occlusion •low-lying placenta, polyydraminos

Uterine •complete transection of the uterus from •sudden extreme Fetal HR: bradycardia MC IMMEDIATE laparotomy & fetal delivery
Rupture endometrium to the serosa abdominal pain •followed by uterine repair
•life-threatening to mother & fetus •decreased/absent Uterine Dehiscence: peritoneum intact
uterine contractions *if uterus repaired, all future pregnancies
Risks: previous rupture, prior C-section •abnormal bump will be a C-section
Decreased Risk: prior vaginal delivery •vaginal hemorrhage

OBGYN About Clinical Presentation Diagnostics Treatment

PROM/ Rupture of amniotic
PPROM membrances before the onset
of labor (<37 weeks)
Risks:
STIs, smoking, prir preterm
delivery, multiple gestations
•GUSH OF FLUID or Sterile Speculum Exam: Expectant: admit with monitoring, await labor
persistant leakage of •pooling of secretions in posterior fornix
fluid from the vagina Labor induction: if no labor within 18 hours then give
Nitrazine paper test: turns blue if pH >6.5 Prostaglandin cervical gel or Oxytocin
Complications:
•chorioamnionitis Fern Test: amniotic fluid-dry fern pattern <37 weeks (PPROM):
•endometriosis (crystallization of estrogen and amniotic fluid) •Betamethasone (< 34 weeks)
•ABX (Ampicillin + Azithromycin)
US: check amniotic fluid index •tocolytics to delay delivery
Normal fetal heart rate is between 120-160 bpm
 > 160 for 10 minutes fetal tachycardia
 < 120 for 10 minutes fetal bradycardia

Nonstress testing - the nonstress test is a simple, noninvasive way of checking on the baby's health. The test records movement, heartbeat, and contractions. It notes changes in heart
rhythm when the baby goes from resting to moving, or during contractions if the mother is in labor
 GOOD- Reactive NST - > 2 accelerations in 20 minutes defined by increased fetal heart rate of at least 15 bpm from baseline lasting > 15 seconds, indicates fetal well being
 BAD - Nonreactive NST - no fetal heart rate accelerations or < 15 bpm increase lasting < 15 seconds, if this is the case then get a contraction stress test

Contraction stress test - measures fetal response to stress at times of uterus contraction
 GOOD - Negative CST - No late decelerations in the presence of 2 contractions in 10 minutes, indicates fetal well being, repeat CST as needed
 BAD - Positive CST - Repetitive late decelerations in the presence of 2 contractions in 10 minutes, worrisome especially if nonreactive NST, prompt delivery
Postpartum Care 6%-normal physiology change

Labor About Diagnostics Management

Postpartum High risk for postpartum hemorrhage
Hemorrhage
4Ts: tone, trauma, tissue (placental retained), thrombin
*MC cause is uterine atony (unrepearid lacerations)
Exam: Atony Treatment:
soft flaccid boddy uterus (uterine atony) •bimanual uterine massage & compression 1st line
•IV Oxytocin to increase uterine contractions
DX: •Methylergonovine or Prostaglandin analogs
•blood loss >1000cc regardless of route
•S/S hypoveolemia Retained Products: suction & curettage
•additional IV access
•type and cross match for blood Uterine Introversion:
•manual reposition
•uterine relaxation: NTG, Terbutaline, Mg Sulfate
•removal of placental fragment or repair of lacerations

Endometritis •infection of decidua (pregnancy endometrium) •fever, tachycardia •clinical

•possible vaginal bleed (foul-smell)
Risks: C-section, PROM, vaginal delivery, D&C, mult, •abdominal pain & uterine tenderness
pelvic exams
2-3days post C-section, postabortal

Perineal Lacerations:
1st degree: perineal skin and vaginal mucosa
2nd degree: injury to perineal body
3rd degree: through external anal sphincter
4th degree: injury through rectal mucosa
*3rd and 4th degree require surgery

Episiotomy:
•surgical incision of female perineum
•increases diameter of soft tissue pelvic outlet to allow delivery
•rationale: reduce 3rd and 4th degree lacerations,
•indications: fetal distress
•complications: vaginal bleeding, increase potpartum pain, unsatisfactory anatomic results, sexual dysfunction, infections
•types: midline, mediolateral (MC)

Postpartum (Puerperium)
Uterus: level of umbilicus after delivery
Lochia Serosa: pink/brown bleeding esp. day 4-10
Structural Abnormalities 5%

OBGYN About Symptoms Diagnostics Treatment

Ovarian •Surgical emergency: ischemia Classic: Doppler sonography (best) Laparoscopy or Laparotomy
Torsion •unilateral low abd pain •disruption of normal Doppler blood •detorsion of adnexa
•prompt diagnosis critical for •MC right side flow to ovary -persistant black-blue discolor is NOT necrosis
preserving function •may radiate to flank, thigh, groin, •specific findings: •cystectomy often done at surgery
may develop after exertion -multiple follicle rimming ovary •if necrotic  oophorectomy
•usually due to ovarian •N/V, adnexal mass, vaginal bleed -bulls-eye, whirlpool, snailshell
enlargement (cyst) •can occur during pregnancy -rounded, enlarged ovary •Post-Op monitor: fever, WBC, peritonitis
•Management similar during pregnancy
•pregnancy test (r/o ectopic) -If removed <10weeks, progesterone

OBGYN About Clinical Presentation Diagnostics Treatment

Uterine •uterine herniation into vagina •vaginal fullness, heaviness, “falling out” Grade 0: no descent •kegel exercsies, behavior
Prolapse •low back, abdominal pain Grade 1: descent into upper 2/3 modifications, weight contraol
Risks: weak pelvic supports •worse with prolonged standing Grade 2: cervix approaches introitus •pessaries
•childbirth (MC) •relieved with lying down Grade 3: cervix outside introitus •estrogen *may improve atrophy
•multiple vaginal births •urinary urgency, frequency, stress incont. Grade 4: entire uterus out of vagina
•obesity Surgery: hysterectomy
•repeated heavy lifting *cystocele, enterocele, or retocele

Cystocele: posterior bladder herniating into anterior vagina

Enterocele: puch of Douglas-small bowel herniating into upper vagina

Rectocele: sigmoid colon or rectum herniating into posterior distal vagina

Other 5%-sexual assault

Natural Methods Periodic Abstinence

Contraceptive Coitus Interruptus (pull out):
Methods •withdrawal of penis before ejaculation
(Natural)
Post-coital Douche:
•water, vinegar, commercial product
•theory: flush semen out of vagina
Lactation Amenorrhea:
•suckling  reduced GnRH, LH, FSH
•anovulatory menses for 1st 6mo if
exclusively breastfeeding (not 100%)
*not effective if supplemental feeding
•need amenorrhea to be effective
•recommended to use contraceptive
starting 3 months after delivery
Periodic Abstinence:
•avoid sex during time when ovum
and sperm could meet
*2-3d before  2-3d after
•methods: calendar, temperature,
combined temperature/calendar,
cervical mucus (billings),
symptothermal method
most effective determinant: LH
•possible increased incidence of
congenital anomalies among
children resulting from unplanned
pregnancies
Calendar Method:
•ovulation after recording
menstrual pattern for several mo
•ovulation normally 14d before
1st day of next menstrual period
•fertile interval: min 2d before
ovulation to min 2 day after
•regular menstrual cycle
•MC method of period
abstinence and least reliable
Ex. Cycle Beads
•white: stop having sex
•brown: ok to have sex
•red bead: period
Combined Temp/Calendar
•well-motivate & compliant
•failure rates 5/100
Temperature Method
•more efficacious than calendar method
•records basal body temp
•take in AM before activity
•slight drop in temp 24-36h after ovulation,
temp rises 0.3-0.4C and stays there
•third day after onset of elevated
temperature-end of fertile period
Cervical Mucus Method “Billings”
•observing changes in cervical mucus
•several days before to just after ovulation
becomes thin and watery
•rest of menstrual cycle: thick & opaque
Symptothermal Method (most effective)
•combines cervical mucus and temp
•uses symptoms before ovulation
•bloating, tenderness, increased libido,
spotting, nausea, headache, mittelschmerz

IUDs Administration/MOA Side Effects Contraindications

Copper IUD •Lifespan ~10 years Risks/SE: Contraindications:
“ParaGard” •PID, ectopic pregnancy •intrauterine contents: pregnancy or suspected pregnancy,
MOA: spermicidal, interfere with ovum •spontaneous abortion previously displaced, distorted uterine cavity (fibroids)
development or fertilization, cause inflammation •uterine perforation
of endometrium •expulsion •infections: PID, postpartum or postabortal endometriosis or septic
abortion, mucopurlent cervicitis
Failure: 0.6% per year, typical 0.8% per year Minor SE: menstrual irregular,
cramp, vaginitis •uterine or cervical cner: genital bleeding
•wilson disease
Levonorgesterl •LNG-20 Intrauterine device 52mg Risks/SE: •Liletta: similar but approved for 3 years
IUD “Mirena” •lifespan ~5 years •ectopic pregnancy
•PID •Skyla: lower dose (13.5mg), smaller device size, smaller tube size
MOA: thins endometrium, thickens cervical •spontaneous abortion for insertion  good for small uterus, low expulsion rate
mucus, decreased tubal motility •uterine perforation -duration: 3yrs, NOT approved for heavy flow, dysmenorrhea
•Irregular menses 1st 3-4 months •expulsion
•after: significant decrease in menstrual flow, •Kyleena: lower dose (19.5mg), last ~5 years, smaller size
dysmenorrhea tends to improve Minor SE: -not approved to treat heavy menses or dysmenorrhea
•irregular menses, HA
Failure: 0.1% per year, 0.7% after 5 years •acne, mastalgia Contraindications: Acute PID unless there has been a subsewuent
intrauterine pregnancy, beast cancer, acute liver disease
Long-Acting About/MOA Benefits Side Effects
Depot •150mg 17-acetoxy-6-methyl progesterone IM q3mo Benefits: Major side effect: decreased bone density
Medroxyprogesterone •Take up to 10 months to return to baseline fertility •lower risk of ectopic pregnancy •osteoporosis, calcium loss
Acetate •lower risk of endometrial cancer •can cause irregular menses
“Depo Shot” MOA: Thick mucus & thin endometrium •lower risk of sickle cell crises •prolonged menstrual flow and spotting for
•may improve endometriosis first 6 months
Perfect: 0.3 pregnancies/100, Typical: 3 preg/100 women •dose not increase risk of vascular disease •often amenorrheic later in course

Implants •Single-rod implant; etonogestreol, progesterone •No major complications SE: irregular menses, weight gain
“Implanon” •Efficacious for up to 3 years; Very high efficacy
“Nexplanon”
Vaginal Ring •Flexible ring 5cm diameter and 4mm thick Failure rate: 0.65/100 women •SE similar to COCs
“Nuvaring” •less breakthrough bleeding and spotting
Combo: ethyinyl estradiol and etonogestrel
•works3 weeks/month •vaginal discomfort, leukorrhea, vaginitis,
•maintains efficacy even if removed for up to 3 hours coital problesm
•designed to be left in place during intercourse

Transdermal Patch Combo: norelgestromin and ethinlyl estradiol daily •Higher failure rate for women >198lbs •CI, SE, risks same as COCs
“OrthoEvra” •New patch wkly x 3 weeks followed by patch-free wk
“Xulane” •Attempt to reattach if comes off •slightly more breast symptoms and
Sites: buttocks, lower abdomen, upper out arm, uppter •Detached <24 hours: continue as usual dysmenorrhea (painful cramps)
torso (except breast) •Detached >24 hours: new patch, backup
contraception x1 week

About Combo New Formulation Combo

Oral OCPS: oral contraceptive pills Estrogen: ethanyl estradiol (MC),
Contraceptives mestradiol, estradiol valerate
COCs: combo oral contraceptives
estrogen & progestin Progestin: norethindrone,
levonorgesterel, desogestrel, gestodene,
POPs: progestrin-only norgestimate
•Highly effective when taken as •3rd gen (Desogesterol, norgestimate)
directed and 4th gen (Drispirenone)
-good for hirsutism & acne
-bad because thromboembolism
•Less hormones  less SE
•Monophasic: same dose of
hormones daily
•Multiphasic: different doses of
hormones during cycle
*most now trying to mimic hormone
levels in cycle
•21 days of active hormone,
followed by 7 days of placebo
•84 active pills, 7 days placebo
•365 active pills
•withdrawal bleed 2-5 days after
stopping active pills
 progesterone drops

Emergency About Yupze Plan B Copper IUD

Emergency •Preventive contraception after
Contraception unprotected intercourse or failure to use
a contraceptive method properly
3 methods: *ideal within 72 hours
•Yupze method
•Levonorgestrel (Plan B)
•Copper IUD (most effective)
•Will not prevent contraception later in
•COCs with Levonorgestrl
•100ug ethinyl estradiol and 500-600ug
levonorgestrel
•2 doses, 12 hours apart
•1st dose within 72h of intercourse
*can do with your birth control
MOA: inhibits or delays ovulation
SE: nausea & vomit
•2 doses of 750us 12 hours apart
1st dose-recommended within 72hrs of
intercourse
•may be effective as long as 5 days
after intercourse
•single dose of 1500ug may be as
effective as 2 dose
•may inhibit implantation or
interfere with sperm function
•insert up to 7 days from time of
intercourse
*good for missed 72h window
*can leave in after and use as a
contraceptive method
•most effective method of
 cycle
Oral Administration
Combo Oral Ideal: begin COC 1st day of cycle
Contraceptive
Traditional: begin Sunday following
onset of menses
Quickstart: begin any day of cycle
*may see more breakthrough bleeding if
not at ideal time
•Encourage regular routine of taking
pills same time daily
Missed pills:
•Single missed dose, high-dose
monophasic: conception unlikely
•Multiple missed or missed dose of
lower-dose pills: double next dose &
add barrier contraceptive for 7d
•Any missed pill + coitus in past 5d:
consider emergency contraception
Progestin •Norethindrone (pill)
Only
•Small quantity of progestin alone
 does not suppress ovulation
•Take at the same time every day
•pre-medicate with antiemetic
MOA & DDI
MOA:
•Suppress ovulation & implantation
•act on LH a&nd FSH  no follicular
•works on midcycle LH surge
DDI:
•Increase/Decrease effectiveness of
medication
-analgesics: Tylenol, opioid
-Other: warfarin, lamotrigine,
benzos, corticosteroids,
theophylline, metoprolol
•Reduced OCP efficacy
-ABX, anticonvulsants, sedatives
•thickens cervical mucus
•thins endometrium, suppress ovulation
Ideal candidates: smokers >35, HTN,
migraines, breast feed, sickle cell, lupus
Benefits & Disadvantages
Advantages:
•improves dysmenorrhea, abnormal
uterine bleeding, acne, hirsutism
•Reduced cancer risk (ovarian and
endometrial) *decreases turnover
•MSK: improves bone mass, protects
against osteoporosis
Disadvantages/Side Effects:
•hypercoaguability: MI, CVA
•cervical dysplasia/CA, breast CA
•gallstones and gall stasis
•increased fluid retention
•increased TG
•diabetes mellitus
•nausea, dizzy, weight gain, decreaed
libido, abnormal menses
Benefits:
•safe in women who cant take estrogen
•safe during lactation
•reduces risk of endometrial cancer
Disadvantage:
•must take SAME TIME daily
•higher incidence of irregular bleeding
•higher overall pregnancy rate
emergency contraception
SE & Caution
CI:
•pregnancy
•undiagnosed vaginal bleeding
•migraine with aura
•women at increased risk of
cardiovascular sequelae
*uncontrolled DM, HTN, lupus
•cigarette smoker over 35yo
•current or prior breast cancer
•active liver disease
Caution:
•may cause/worsen HTN or HA
•may impair quality/quantity of
breast milk
CI:
•unexplained bleeding
•breast cancer
•hepatic neoplasms
•pregnancy
•active liver disease
 Barrier/Physical
Spermicides •active ingredient: nonoxynol-9 or octoxynol-9 •Must be placed high in vagina, in contact •High pregnancy rate due to inconsistent use
•physical barrier and chemical spermicidal with cervix, short before intercourse -do NOT protect from STDs
•max duration: 1 hour, avoid douching for -can cause local inflammation
at least 6 hours

Sponges •Nonoxynol-9-impregnated polyurethane disc •Efficacy unchanged by frequency of sex

-inserted up to 24 hours prior ot intercourse •More convenient but less effective than
-must remain in place for 6 hours after coitus diaphgram or condom

Male condoms •Cover for the penis during coitus •Latex-may be polyurethane or lamb ceca Advantages:
-prevents deposition of semen in vagina •lambs cecum not impermeable to most •highly effective, inexpensive, protect againt STIs, may
-MC used mechanical contraceptive organisms have spermicides

•should be recommended for ALL couples Failure: imperfections, errors, semen escape

Female condom •Thin polyurethane with 2 flexible rings Advantages: Disadvantages

-one ring: depth of vagina •under control of female partner •relatively expensive
-one ring: near the introitus •some protection against STDs •overall bulky

Diaphragm and •Circular rubber dome supported by a metal spring
Spermicide
•MUST USE WITH SPERMICIDE-cervical side
-ineffective without spermicide
•Mechanical barrier between vagina and cervix
•Position so that the cervix, vaginal fornices,
and anterior vaginal wall are partitioned
from the ramined of vagina and penis
•place up to 6 hours before intercourse
•leave in place 6-24 hours after
•Trial and error to find correct size
-too small: ineffective, too large: uncomfortable
-weight changes can change size needed
SE: vaginal irritation, increased UTIs
-some protection against STIs

Cervical Cap •Small, cuplike diaphragm placed over cervix •Similar efficacy to diaphragm Disadvantages:
-held in place by suction •leave in place for 8-48 hours after sex •difficult to fit cap properly
-must fit tightly over cervix •confirm placement over cervix after each •may use for 1-2 days, but foul discharge usually
-may be used with spermicide sexual act develops after 1 days

Elective Abortion
Medical:
- Mifepristone (Mifiprex)  Misoprostol (Cytotec) 24-48h after *safe up to 10 WEEKS
o Mifeprostone: progesterone receptor antagonist (dilation and softening of cervix, placental separation)
o Misoprostol: prostaglandin E1 analog (uterine contractions)
- Methotrexate  Misoprostol 3-7days later *safe up to 7 WEEKS
o Methotrexate: folate antagonist
Intra-Amniotic: induced abortion after 1st trimester
Surgical: can be done up to 24 weeks
- Dilation and Currettage (D&C): includes usage of curette or suction *4-12 weeks gestation
- Dilation and evacuation (D&E): >12 weeks
Post-Abortion: rhoGAM to all RH (-) pts; avoid intercourse, tmapons, douches, intra-vaginal products for 2 weeks
- 2+ procedures can increase risk of mid-pregnancy loss
INFERTILITY
Inability to conceive after 1 year of unprotected sex in women <35yo or in 6 months in women >35yo
Primary: no pregnancies, Secondary: following at least one prior conception
Sequence of events: Ovulation Ovum pickup in fallopian tube  Fertilization  Transport of fertilized ovum into uterus Implantation  Receptive uterine cavity

Infertility Males Females

Infertility Male History
•hypospadias, cryptochordism
•abnormal spermatogenesis
•ejaculatory dysfunction
•STDs, mumps
•testicular trauma, torsion,
varicocele
Male Causes
•Abnormalities in sperm production
•Abnormalities of sperm function
•Obstruction of ductal outflow
Spermatogenesis:
•Takes 90 days from stem cells to
mature sperm (70d to produce)
•12-21 days for sperm to travel into
the epididymis *best at cooler temp
Semen Analysis:
•Refrain from ejaculation for 2-3d
•Specimen collected in sterile cup
•test for anti-sperm antibodies
TX: corticosteroids
Semen Volume:
•obstruction of vas deferens
•retrograde ejaculation
Spem Count:
•Oligospermia: <20mil  IUI
•Azoospermia: none  donor
Sperm Motility & Morhpology
Motility: Astehnospermia:
•TX: intracytoplasmic injection
Morphology: teratospermia:
•TX: IVF
GYN
•Menstruation
•Prior contraceptives
•Duration of infertility
•Hx cysts, endometriosis, leiomyomas,
STDs, PID, abnormal paps
OB: prior pregnancy; complications
COITAL
•Timing: chance of conception increased 5d
preceding ovulation  daily sex
•Dyspareunia
•chemotherapy, radiation
•androgen excess  PCOS
•thyroid, hyperprolactinemia
•medications
•BMI
Social History
•lifestyle, diet, smoking, alcohol, caffeine,
ilicit drugs, ethnicity, oil based lube
Causes:
•ovulatory disorders: hypothyroidism,
hyperprolactinemia, PCOS
•pelvic adhesions
•tubal blockage or other tubal problems
•uterine or cervical factors
•unexplained
Managmenet:
•Clomiphene (Clomid) induces ovulation
•IVF (esp if fallopian tube defect)
Diagnosis:
Hysterosalpingography to evaluate
tubal patency or abnormalities
Temp:
•oral temp 97-98F during follicular
•postovulatory rise in progesterone
levels increase basal temp by 0.4-0.8F
 this rise is STRONG evidence that
ovulation has occurred
Ovulation Predictor Kits: TEST LH
•test 2-3d before LH surge and daily
•test with first morning void
•ovulation will occur the day after the
LH peak
Serum Progesterone
•check day 21 or 7 days after ovulation
•limitations: secreted in pulses and
single measurement not always reliable
Serum FSH/Estradiol
•inhibin inhibits FSHincrease FSH
•typically done on cycle day #3
>10 indicates significant loss o
•increasing estradiol level due to
increase in FSH (>80 is abnormal)
Antimullerian Hormone
•expressed by granulos cells or small
preantral follicles
Induction Meds MOA/About Route/Dose Complications of Induction
Clomiphene Citrate •Initial treatment for most anovulatory infertile women •Oral medication •multifetal gestation
(Clomid) •Estrogen antagonist  increased FSH  increase follicles •Give for 5d starting on cycle day 3-5
•ovarian hyperstimulation
Aromatase Inhibitors •Inhibitors the production of estrogens •Oral med, Give on cycle day 3-7 -ovarian enlargement due to
(Letrozole) exogenous gonadotropin therapy
Gonadotropins •Urinary recombinant FSH and LH •IM or subcutaneous -due to increase capillary permeability
(Leuprolide) •EXPENSIVE
Intrauterine •Sperm is washed and concentrated S/S: abd pain/distention, ascites, GI,
Inseminationt (IUI) •Long, thin catheter threaded through the cervical os into respiratory compromise
endometrial cavity  sperm put into endometrial cavity
TX: supportive
In Vitro Fertilization •Mature oocytes from stimulated ovaries are retrieved
(IVF) transvaginally  sperm & ova combined  viable embryos
are transferred transcervically into endometrial cavity

Infertilit About Causes Diagnostic Testing Treatment

y
Tubal •Dysmenorrhea or chronic pelvic infection: increase in the occurrence of Hysterosalpingogram Tubal Occlusion
and pelvic pain may suggest PID, increases the risk of adhesions and •injection of a radio-opaque medium thru the •tubal cannulation
Pelvic infertility vertical canal to evaluate the uterine cavity and •tubal reconstruction
Factors •Adhesions prevent normal tube •endometriosis tubes •tubal resection  IVF
movement, ovum pickup and •prior pelvic surgery •usually performs on cycle day 5-10
transport of fertilized egg into Endometriosis
the uterus Chromopertubation •surgical treatment
•injection of methylene blue through cervical •IVF
canal during laparaoscopy to evaluate tubal •GnRH  long term
patency
-want to see the dye come out-shows no Pelvic Adhesions
adhesions present •surgical removal, IVF

Female Anomalies Fibroids Asherman’s Syndrome Polyps

Uterine Congenital anomalies: •can obstruct a fallopian tube, distort the •intrauterine adhesions diagnosis: hysteroscopy
Factors •uterine septums uterine cavity or fill the uterine cavity •occurs most often with a history of D&C
•mullerian anomalies •endometrium overlying is less vascular DX: HSG or hysteroscopy TX: hysteroscopic removal
DX: HSG and US TX: hysteroscopic lysis of adhesions
TX: >5cm  myomectomy, resection

Female About Causes Diagnostic Testing Treatment

Cervical •Cervical glands secrete mucus
Factors
•mid cycle high estrogen levels
cause mucous to become thin
and stretchy
 creates reservoir for sperm
•hx LEEP or cone surgery Indications of appropriate mucus: •IUI
•cryosurgery •mucus should stretch >5cm
•cervical infection •visualize 4+ motile sperm on microscopy
•minimal inflammatory cells on microscopy
Postcoital test
•couple has intercourse on day of ovulation
•women present to office a few hours later and
 a sample of cervical mucus is obtained

OBGYN About Symptoms Diagnosis & Treatment

Functional •may have symptoms, may be asymptomatic Symptoms result of: Diagnosis:
Ovarian Cyst -menstrual irregularities -rupture of contents with chemical peritonitis •may be able to identify on pelvic exam
-pelvic pressure or pain -torsion of enlarged ovaries •pelvis US
-large: constipation or urinary frequency -mechanical pressure

Follicular Cyst MOST COMMON functional ovarian cyst
•size: 3-8cm
•cause: due to failure in ovulation
-incompletely developed follicle
S/S: usually asymptomatic
•may see bleeding and torsion
•may cause aching pelvic pain, dyspareunia
•may see bleeding and torsion
•observation, symptomatic
•usually resolving in 2 months
•OCPs: recommended, may not speed resolution
of current cyst but can help with future cysts
•aspiration: not though to help

Corpus Luteum •size: 3-11cm S/S: Treatment: asymptomatic

Cysts •cause: accumulation of fluid inside corpus •asymptomatic or local pain, tenderness, amenorrhea •usually resolve spontaneously within 2 months
luteum or delayed menstruation •OCPS: recommended
-associated with Clomiphene (Clomid) -torsion or cyst rupture and bleeding •surgical: if hemorrhaging or torsion

Theca Lutein •size: at least 3cm S/S: minimal sx Treatment: symptomatic

Cysts •Cause: elevated levels of hCG •pelvic heaviness or aching •gradually resolve as hCG levels return to normal
-hydratiform mole, choriocarcinoma, •rupture and bleeding or torsion •may take months to resolve
multiple gestation, hCG therapy •surgery: is torsion or hemorrhage

Endometriomas •size: up to 10cm “chocolate cysts” •Treatment same for endometriosis

•cause: endometic foci on ovarian surface •pelvic pain
-pateint with endometriosis •dyspareunia, dysmenorrhea •may be removed laparoscopically
-develop fibrous enclosure •infertility

Dermoid Cysts Cystadenoma

Other Ovarian •filled with fat, hair, teeth, bone, cartilage •develop from cells on outer surface of the ovary
Cysts •rarely neoplastic but may rupture •benign but can grow large and cause pain

Disorder About Criteria Treatment

Intimate •1/4 women, 1/7 men one in lifetime Clues: •screening, assessing, referring
Partner •women who leaves abusive partner has 70% > risk of being killed •contusions to chest ,breast, abdomen, face, neck •adress pateints directly with non-
Abuse •pregnancy abuse can make up 10% pregnancy-related hospital •MSK and “accidental injuries” threatening questions
admissions •multiple injuries in various stages of healing

Sexual •common ages 9-12 years old Clues:

Abuse •MC perpetrators: males, relatives, known by child •children with sexual knowledge
•initiate sex acts with peers or show knowledge
•bruises, pain, pruritis in genital or anal area

Physical •abuser often female and primary caregiver •cigarette burns, burns in stocking glow pattern
Abuse •laceration, healed fracture, subdural hematoma

OBGYN About
Endometriosis •endometrial growth outside uterus
•ectopic endometrial tissue responds
to cyclical hormones changes
Risks: prolonged estrogen exposure
•FHX, early menarche, nulliparity,
long flow, heavy menstrual bleeding,
shorter cycles
(-) Risks: exercise, late menarche,
higher parity, longer lactation
Common site: ovary (MC), uterine
cul-de-sac, pelvic ligaments, uterus,
fallopian tubes, large intestine
Leiomyoma •benign uterine smooth muscle tumor
•MC benign gynecologic tumor
Types:
•intramural: completely within
•submucosal: beneath endometrial line
•subserosal: beneath serosal lining
•parasitic
Risks: increase age, African
American, nulliparity, obesity, fhx
Adenomyosis •islands of emdometrial tissue within
the myometrium (muscular layer)
Risks:
•later in reproductive years
•multiple bruises, retinal hemorrhages
Clinical Presentation
CLASSIC:
•dysmenorrhea
•pelvic pain
•dyspareunia
•infertility
•constant pelvic pressure through menses
•may have bloody urine or bowel
•dyschezia (painful defecation)
Phyiscal Exam:
•tender nodules in posterior voaginal
fornix or uterosacral ligamnets
•pain with uterine motion
•most are asymptomatic
•bleeding MC (menorrhagic, irregular)
•dysmenorrhea
•pelvic pressure or pain
Exam: firm, nontender, asymmetric mobile
mass or masses in the abdomen, pelvis
•menorrhagia
•dysmenorrhea
•chronic pelvic pain, possible infertility
Exam: symmetrically enlarged
“globular” bogggy uterus
Diagnostics Treatment
Transvaginal US: Minimal to Mild SX
modality of choice •NSAIDS
•COCs or progesterone only
•MRI 1st line!
Laporoscopy with Biopsy: Moderate to Severe
DEFINITIVE •GnRH agonists, Aromatase inh.
•Early: small, red, petechial •Danazol, (testosterone derivative)
•Large: cystic, dark brown, dark blue
•Peritoneum: “powder burn” and Surgery:
“chocolate cysts” •laparoscopy with ablation of
ectopic endometrial tissue
•total abdominal hysterectomy
with bilat salpingo-oophorectomy
if no desire for fertility
TVUS: Asymptomatic: observation
•focal heterogenic hypoechoic mass
or masses with shadowing Symptomatic & fertility:
•nonsurgical (Leuprolide)
MRI: delineates intrmural v •myomectomy
submucosal
Symptomatic, no fertility:
Hysterography: confirm cervical or •nonsurgical (Leuprolide)
submucous •myomectomy, myolysis
Symptomatic: Hysterectomy
DEFINITIVE
•clinical diagnosis *preserve fertility
•TVUS *preferred •analgesics
•MRI more accurate •progestins, aromataste inhibitors
•post-total abdominal hysterectomy
total abdominal hysterectomy
ONLY effective therapy
Incontinence Disorders Causes/About
Urge Incontinence •Detrusor overactivity (stimulated by
muscarinic Ach receptors)
*more common in elderly  uninhibited destrusor contractions
during bladder filling
Causes: old age, idiopathic, infection
Stress Incontinence •Urethral sphincter incompetence
•Hypermobility: weak pelvic floor
*seen in younger women •Intrinsive sphincter deficiency
Overflow Incontinence •Detrusor underactivity
•Non-contractile bladder  distented
Causes:
•neurologic (MC): DM, MS, spinal
injury, neuropathy with B12
•obstruction: BPH, fibroids, prolapse
Mixed Incontinence •Multiple causes
*very common, esp •most often stress + urge
women
Functional Incontinence •Problems thinking/ speaking/ moving
•Inability to recognize need to
*MC in women urinate or to get to restroom
-psych/neuro or mobility
Incontinence Disorders MOA
Anticholingerics Inhibit acetylcholine at muscarinic
Oxybutynin receptors
Tolterodine •blocks parasympathetic pathway
Darifenacin leading to bladder contraction
Trospium
Soligenacin *individual patients respond
Fesoterodine differently, all equal efficacy
Mirabegron Beta-3 agonist
*patients who cannot tolerate
Signs/Symptoms
•Very strong urge to urinate
immediately preceding & while
involuntary urine passage
•few drops or totally soaked
•Involuntary urine leakage with
increase in abdominal “pressure”
-cough, sneeze, laugh, lifting
•abdominal pressure > urethral
•Frequent involuntary leakage of
small amounts of urine +/- nocturia
•Weak urinary stream, bladder fullness
DX: PVR >200ml
Combination of sx from other forms
Varies with underlying cuase
Side Effects
•Dry mouth
•Constipation
•Dizziness/drowsiness
•Blurred vision
•Decreased cognition
*special caution in elderly
*may decrease SE with XR forms
•HTN
•tachycardia
Treatment
Bladder training: timed frequenct voidings, voiding diary,
Diet: avoid scpicy foods, citrus fruit, chocolate
Lifestyle: kegel exercises; less alcohol, caffeine, fluids
Pharm: antimuscarinics (Tolterodine, Oxybutynin) *1st line
•Mirabegron: Beta-3 agonist  bladder relaxation
•TCAs (Imipramine): central & peripheral anticholingeric effect
Surgery: botox, bladder augmentation
1st line: lifestyle & kegel exercises
•Pessaries (if bladder prolapse)
•surgery (last resort, most effective)
•Lifestyle Modifications, Kegels
•intermittent or indwelling catherization
Meds:
•anticholinergics (Bethanecol)
•Mirabegron, TCAs, alpha-blockers in men
•Lifestyle Modifications (same); Kegels
Meds: same as urge incontinence
Botox injections, surgical sling
•Lifestyle + bedside commode & call bell + kegels
Tx underlying: Evaluate delirium, mobitlity aids, physical therapy
DI/CCI
CI:
•gastric retention
•glaucoma
DDI:
•other anticholinergics
•potassium chloride (can cause irritation and ulcers of GI tract)
CI: allergy
anticholingeric therapy or OAB •dry mouth DDI: other anticholinergics, QT prolongating drugs
•constipation, UTI
Human Sexuality
Biologic Gender: external genitalia or chromosome
Intersex: individual with genetic, hormonal, and/or physical feature of male and female
Gender identity: sense of feeling male, female, neither, or both
Sexual Identity: how one thinks of onself in terms of whom one is romantically attracted to (straight, lesbian, queer, bi)
Sexual orientation: described the object of a persons sxual impulse and attractions (heterosexual, homosexual, bisexual, pansexual)
Sexual Behavior: specific actions and behaviors involving activities (psychophysiological)
Gender Expression: how one presents ones gender to others
Gender discorgance: discrepancy between biologic gender and gender identity

Transsexual: discordant people who make changes to their perceived gener to conform to their identity
Cisgender: identy, expression, and biologic all align (man, masculine, male)
Transgender: person who is not cisgender
Genderqueer: gender identitiy is neither masculine nor feminine

Sexual Response: attitude toward sexuality and towards ones sexual partner
1. Phase 1: Desire (Libido)
2. Phase 2: Excitement and Arousal
3. Phase 3: Orgasm
4. Phase 4: Resolution

Hormones increased: dopamine, testosterone, estrogen

Hormones inhibited: serotonin, progesterone

Gravida: number of times a woman have been pregnant

Parity: Number of pregnancies that led to a birth either at or after 20 weeks
- T (term)  number born at 37 weeks or older
- P (preterm)  born after 20 weeks but before 37 weeks
- A (abortion)  all pregnancy losses prior to 20 weeks
- L (living)  infant who lives beyond 30 days

Nulligravida: woman who currently is not pregnant and never has been pregnant
Primigravida: woman who currently is pregnant and has never been pregnant before
Multigravida: woman who currently is pregnant and who has been pregnant before
Nullipara: woman who has never completed a pregnancy beyond 20 weeks
Primipara: woman who has delivered a fetus or fetuses born alive or dead with an estimate length of gestation of >20weeks
Multipara: woman who completed 2+ pregnancies to 20 weeks gestation or mo