Obstetrics 2.

Genital and extragenital changes in the organism of the

1. Diagnosis of early and late pregnancy pregnant woman.
The diagnosis of pregnancy requires 3 main tools; Hx and PE, lab, US Genital changes; Extragenital changes
Total time; 1-UTERUS; softens (6w), Breasts and lactation :earliest changes is a
1st trimester; 12w Progesterone relaxes the SM, to swelling of the breast tissue.
2nd trimester; 13-28th stretch, increase in size, ascends, oestrogen leads to increase in number of
3rd trimester; 29-42th begin to contract around 3rd glandular ducts.
Early Late (2nd/3rd trim.) trimester (Braxton Hick’s prolactine leads to active secretion of milk
History +Sx Sx contractions) after birth.
- Amenorrhae - Amonorrhea, enlarged abdo Vagina; mucosa becomes thicker, Hemato changes;
- Morning Sickness (until 12w) - Dec. hCG after 12w. discharge during pregnancy - ; Plasma volume, total blood volume, WBC,
- Urinary sx (frequency - Inc. Pigmentation, Chloasma (around Chadwick, Hegar's, Piscachech ESR, Fibrinogen, CO and stroke volume
nocturia) 24w) and Palmar’s signs
; RBC, Hb,Hct,Platelets, BP
- Breast discomfort,mastalgia, - Fetal movement Hormones produced by uterus
Cause problems like; physiological edema,
- Fatigue (until 16-18w.) - Palpating fetal parts 1-beta-hcg; serum 10d after
anemia, BP, supine hypotensive syndrome
- Fetal movement (16-20w) Abdo exam conception. high in early
(bradycardia, dizziness,light-headed)
constipation, weight gain - Inspect: Stirae, enlarged abdo pregnancy (for implantation and
Pulmo; increase O2 consumption, decrease
Genital changes; - Inc. fundal height; W-16 Mid of pubis development), to support corpus
respiratory capasity and pulmonary reserve
- Chadwick sign bluish /umbilicus, luteum secretion of oestrogen
and tendency to hyperventilatea, dyspnea
color of cervix, vagina & labia W-22-24 umbilicus, W-36 Xiphold and progesterone in the first
Urinary system; increase blood flow to
(6-8W) process trimester until the placenta
kidneys and GFR, susceptible to bladder and
- Hegar's sign Isthmus, lower * Symphysis Fundal Height; becomes able to produce these
kidney inf., polakiuria and incontinence
uterus soften - From symphins to top of uteres; 24-26W hormone.
Endocrine system
- Piscachech sign Palpation of  -/+2 cm gest. weeks. the peak level normally occur in
; prolactine, Insulin (insulin resistance
conception LEOPOLD MANEUVER the 12th week. In late pregnancy
develop), Estrogen, Progesterone, Relaxin,
- Palmar’s sign Uterus 4 maneuver → lie, presentation, position it helps; supressing mothers
Thyroid; t3-t4  (tsh decrease),
contraction on bimanual exam. 1- fundus (shape, mobility) immunity against fetus, control
corticosteroid , aldesterone  , angiotensin
(4-8W) 2- Both sides (direction of back) fetal hormone secretion
and renin 
Immuno Test; 3- Inlet Part of fetus in inlet 2- Human placental lactogen;
; GH is suppressed .
- hCG 8-9d after fertilisation, 4- Degree of fetal extention into pelvis increase when the level of HCG
GIT; Digestion slow down due to
Peak at 2-3rd month Vaginal exam; start to drop (after placental
progesterone, Constipation Nausea and
- US TV or TA , - US No of fetus, anatomy, amniotic delivery in 7-10d HCG disappear);
vomiting,Heartburn
Sac; 5W, Yolk sac; 6W , fluid effects lactation, breast growth,
Ptyalism (salivation), Hemorrhoids, gum
Fetus; 6-7W, Heart beat; 7W - Parameters AC, HC, BPD, FL CH and fat metabolism
swelling. Gall stones, cholestasis,
Note; BPD: <3cm in first trimester. FL = 2- 3-Estrogen; early pregnancy;
appendicitis (position of it may be different)
3cm less then BPD corpus luteum, late by placenta.
Skin;
4-Progesterone; Same
• Chloasma or melasma gravidarum
production, act on smooth
• Striae
muscles cause relaxation
• Linea nigra

3. Normal delivery - predictors, stages, management.

Onset of Components of labour ; 3P; Power (Contraction), Passanger
 labour (fetus), Passage (Pelvis) From delivery of placenta until 6-8 Puerperal infections;
1-Regular 1- Power Contractions start spontaneously, occur regularly. w after delivery - Puerperal pyrexia; Rise in >38°, within 10d after
1- Uterus; Reverse from 1kg to 50- delivery. Causes; UTI, sepsis, mastitis, C-section wound.
uterine First every 10-15min, then inc. frequency (2.3min) uterus
100g. Fundus after birth is in Puerperal sepsis;
contractions differentiate to 2 part→ Upper & lower segment umbilicus level. in first 2 w; return Causes; Endometritis, endomyometritis,
2-Effacement 2- Passanger to true pelvis. endoparametritis. Agents; S.aureus, C.albicans, E.coli
of cervix - Presentation Cephalic (vertex, face, sinciput, brow), -Endometrium regenerate in 16d - Sx; inc. t°, headache, malaise, inc. pulse, redness,
3-Rupture of shoulder, breech (Frank, Complete, Incomplete) -Uterine Contractions after birth swelling of wound, purulent copious lochia, spreading
amniotic - Position Relation of presectip part to maternal pelvis. cause hemostasis by compressing infections like peritonitis, septicemia etc
vessels. Tx; Isolate pt, IV fluid, antibiotic. Surgery; Pus drainage
membrane Ex: Occiput transverse, occiput anterior.
- Placental bed decr. by half, UTI; E.coli, Klebsiella, Proteus
(Nitrazine test, 3- Passage Gynecoid, Android (V), Anthropoid, Platypelloid Cause lochia; (discharge, contain RF; C-section, vacuum / foreseps delivery, Catheters,
Ferning test) pelvis mucus, blood, uterine tissue. long hospital stay
*lochia Rubra Red Clinical; Fever, pus/blood in urine, pain
STAGES OF LABOR + MANAGEMENT *lochia Serosa Brownish Dx; History (frequency, urgency, hematuria,etc)
1st stage ; 2nd stage ; Fetal 3rd stage ; Placental *lochia Alba Yellow-white, decr. - Lab; urine analysis, culture, CBC.
amount and odor. Tx: Antibiotic, Diuretic, Antipyretic, IV fluid
delivery. delivery
- Last around 5 weeks. Urinary Retention;
 Dilation of cervix, - 1-2h (1st) - 5-15 min, not >30min 2- Cervix; Rapidly reverse, Never Causes; Brusing,edema of bladder neck, perineal injury.
 Latent phase (0-4cm) ; - around 30min Signs; return completely Tx; Indwelling catheter (48h,) Urinary antiseptics for 7d.
11-12h (1st preg.), 6-8h (multiparus) 1-Uterus become globular - in 1 week closes mostly. Mastitis; - agents: S. Aureus, Strep viridans
(later preg.) - Intense pushing by & firm, 3- Vagina; Reverse but never same. RF; Poor nursing, maternal fatigue, Cracked nipples.
 Active phase ( 4-10 cm) pt; during 2-Sudden gosh of blood, In week 3; resolution of vascularity Types; Breast parenchyma (cellulitis), Lacteferous
+ edema In non- breastfeeding, ducts (adenitis)
* Cervical effacement contractions 3-Umbilical cord loosens, rugae of vagina appear. Clinical; Malaise, headache, fever, pain/swelling,
cervical canal shorten 4-Uterus rise to abd. wall. 4-Perineum;Muscle to regained in redness.
* Cervical dilation 6w. Tx; Milk stasis can managed by heating, massage, fluids.
Widening of cervical os 5- Abdo; soft & poorly toned for Rest, analgesics, manuel expression of milk.
Management; Management Management many weeks. Heals depend on - Antibiotics; Dicloxacillin, Erythromycn.
 Portagram; recording - Inc. HR (120- - Pulling placenta after maternal exercise Venous thrombosis;
6- Ovaries;Normal function highly RF; Age, high parity, vein stasis, trauma.
data 160bpm) signs variable; Clinical; Asymptomatic, Pain in calf muscles, edema in
 Amniotomy - Clean vulva, - Gord traction maneuver *Breastfeed around 36w. *Non- leg, inc. skin temperature.
HR, dilation / effacement, perineum, anal area - Crede morenver breast feed Ovulate around Dx; Doppler US, Venography
pulse, BP etc. - Episiotomy if Examine placenta, mother 27d , Mostly 12w (7-9w). TX; rest, analgesics, anticoagulants, thrombectomy.
needed keep in close observation 7- Breast; Progesterone that trigger Pelvic thrombophlebitis;Develop 2w after puerperium,
for 24 milk production. Pyrexia, headache, malaise, cold, painful area over
*Colostrum liquid from breast in effected leg.
OCCIPUT PRESENTATION first 2-4 days Tx: Heparin IV, Antibiotics.
Occiput anterior; 7 cardinal movements ; Engagement, Descent, Flexion, Int. - High protein, rich Abs Pulmonary Embolism; Sudden collapse, acute chest
Rotation, Extension of head External rotation, Expulsion 8- CVS; Blood Volume normalize in pain, air hunger, tachypnea, dyspnea, tachycardia,
Occiput post; (mostly ROP) Rotate 135°C (int. rot.) or not rotate→ persistant 10d, CO return normal in 2-6w cough, hemoptysis.
post. position. Manifestation; First 24h fever, sweat, Dx; Chest X-ray, angiography.
lochia, pain Uterine subinvolution; uterus not turn to normal size
Occiput transverse; If persist manual rotation; Foreceps. If due to other reasons; Management; 2h Bleeding, CF: Prolonged lochia, vaginal bleeding, large uterus.
like pelvis shape etc may need C-section Contraction, HR +BP manage
Tx; oxytoch (Methergine, Pitocin etc), Antimicrobials
Monitor Micturation, Defecation,
Lochia, Breast, episiotomy, laceration Psychiatric Disorders; 4-5d after delivery
4. Physiological and pathological puerperium. Puerperal - Depression, anxiety, insomnia, helplessness
cares.
Normal (Physiological) Pathological Puerperum
5. Traumatism in labor DELIVERY;
Maternal birth Trauma - Vertex-vertex vaginal
1-Vulvovaginal lacerations 5-UTERINE RUPTURE - Breech-breech vaginal
- Small tears to vaginal wall near urethra 1° intact uterus. - Breech-vertex C-section (interlocking twins)
- Superficial ones not need Suture. Langers 2° previous surgery
 repair. Etio; Surgery especially to Complications;
2-Levator sling injuries myometrium Mother Fetus - morbidity, mortality, malpresentation, IUGR,
- Levator ani involve to deep lacerations - Uterus trauma - Preterm lobar, Congenital anomalies, Cord prelaps etc.
- Muscles torn / seperated. - Congenital problem; Con. spontaneous Twin-twin transfusion;
- Urinary incontinence Tissue disorder abortion, placuta Donor anemia, oligohydromnios, IUGR
3-Cervical lacerations - Stimulated labour previa, abruption Recipient Polycythemia, Polihydr, inc. Amniotic pressure
- Mostly superficial (<0.5cm) no repair. - Overdistended uterus TX;
- Not problematic if not causing hemorrhage - Foreceps, pllscenta accreta etc. - Reduction amniocentesis
or extend to upper 1/3 of vagina Types - Septostomy
* Colporrhexis; rupture of vaginal Vault; - Complete (all layers seperate) - Selective vessel laser ablation
usually due to foreceps - Incomplete (muscle seperate - Umbilical cord occlusion.
Dx; By hemorrhage during or after 3rd stage peritoneum intact) ACARDIA ; monochorionic twins
of lobar Sx; Fetal distress, abdo pain, loss - Heart of one twin is not working or absent, cardiac failure
Tx; <1-2cm not repair of uterus contraction, to other twin.
Deep  Surgery via sutures hemorrhagia, Shock Discordant Growth; weight of one is > 25% different
4-Puerperal hematomas Complications; Fetus hypoxia, IUGR; placental insufficiency, compete for nutrients
- Due to lacerations, episiotomy, operation acidosis, Low APGAR, death Fetal demise; fetal loss, fetal death, urethral damage to
- Cause pain Mother Severe blood loss, other
- Small hematoma expectant Tx. Cystotomy, hysterectomy, death Fetus papyraceus; a twin not develop, become amorphous,
- If pain & continue enlarge Surgery Tx; Hysterectomy or repair. flattered.
6. Multiple pregnancy. 7. Ectopic pregnancy. - Implantation of embryo outside uterus
>2 fetures in uterus Locations; Dx; Physical exam;
RF ; Monozygot; Dizygot - Tubal ampullar & - If total rupture; hypotension, tachycardia,
- Age, Race, family history - 4 type; (%75) tenderness
interstitial
- High parity, infertility TR 1- Dichor / diam
- Ovarian - If no rupture; normal pt.
- ART, ovulation induction. 2- Monoch/dian (most common)
3- Mono/mono - Abdominal Transvaginal US;
4- conjoined - Cervical HCG when >2000 mlu/ml visible sac normally,
Dx; - Heterotropic fetus etc
- C-section scar - Serial hCG test needed to dx ectopic preg.
Hx; genetics, ovulatory drugs etc Symptoms → fatigue, hyperemesis, weight gain etc.
- Loparoscopy
Inspection; inc. Abdo. Etio; PID, tubal surgery,
- Serum progesterone → < 5ng/ml  mean non-
Palpation; - fundal level, Multiple fetal poles, Fetal limbs infertility /ART, Smoking,
viable pregnancy
Auscultation; Arnaux sign (gallop rhytm) IUD.
Tx; Surgery; Salpingectomy, Linear Salpingectomy
US; Sx; vaginal bleeding, abdo - Operative laparoscopy, laparatomy
- Chononicity 5w; (mono; <2mm, di; >2mm membr. Twin peak sign.) pain, dizziness, fainting. - Cornual resection.
- Fetal no 6w Palpitations. - Oopherectomy
- Amniocity around 8w
Medical; Methotrexate
- Seperate heads = 12W
8. Abortions - types, clinical signs and management. PROM- Premature rupture of membranes; means amniorrhexis at any stage of
Expulsion of products of conception <20w or fetal weight <500g gestation before 37w
TYPES; Etio; - Vaginal infections, Dx; History of fluid loss from vagina,
Spontaneous Induced Inc. intrauterine pressure, - Inspection with speculum
Threatened, elective, Trauma, Smoking, Previous - Tests; Nitrazine test  Tum Blue, Fern test
Inevitable, therapeutic PROM, Short cervical seen as crystals, Nile Blue test Red color.
Incomplete, length, Bleeding in early - US
Complete, pregnancy Mangement
Missed, Complications; Preterm - Due to gestational age.
Septic, labor (%75) - <36w → expectant management
Habitual - Intrauterine infections - 36w or more Induce labour
Technique; (Chorioamnioitis) Expectant mongement
Surgical Cur, Vac. D&E. Medical IV. Oxytocin, Prostaglandin, - Puerperal infections - Dexamethasone → lung maturation
Surgical; Antiprogestin For fetus; pneumonia, - Antibiotics
Dil. & Currettage, Medical abortion; sepsis, Neonatal RDS, - Tocolysis
Suction aspiration, - Antiprogestin mifeprostol Neuro dysfunction, Birthweight; Low 2500g, Very low <1500g,
Dil. & evacuation. - Antimetabolite methotrexate intracranial hemorrhage, Extremely low <1000g.
- Prostaglandins misoprostol Umbilical cord prolasse,
Etio; Mother Infection, Trauma, Endocrine (DM, hyperthyroidism), Drugs, Placental abruption.
malnutrition, uterus defect.
Fetus CA, Bilighted ovum, Fail to implant, Placenta previa, Placenta abruption. 10. First cares for the newborn. Premature newborn – signs
9. Preterm delivery. for prematurity, cares.
Premature (Preterm) Labour; Occur after 20w, before 37w Characteristics of newborn;
Characters; Dx; Documented uterine contractions. Anthropometric Signs of maturity;
-Regular uterine contractions. - 4 in 20min. measures; - Premature; <37w GA
- 2cm or more dilation - 8 in 60min. weight, lenght, head - Full-term; 37-42 w GA
- 80% or more effacement Documented Cervix change and chest - Post-term; >42w GA
RF; Previous preterm delivery, Age - 80% or more cervical effacement circumference, Mature in time born baby;
<18 - >40, PROM, Multiple Gestation, - 2cm or more cervical dilation abdominal girth *born btw 37-42w GA,
- Skin, underlying *>45cm (medium 50-52cm),
Maternal history. US, Fetal monitoring.
tissues *weight 2500-4000g, (Very low BW
Causes; Tx; Bed rest,
- muscles, bones, joints <1500g, extremely low BW <1000g)
uterine Myoma, uterine septum, - Tocolytics; Mg sulfate, Terbutaline,
- internal organs Cry loudly, sucks, holds warmness well. Marked physical
Bicarnuate uterus Nifedipine, - Evaluation of reflexes, enough muscle tone, marked movements,
Infectious Vaginosis, - Corticosteroids for fetal maturation; morphological reaction to pupils on light, react bad smell and taste.
pyelonephritis Dexamethasone maturity
Fetal Intrauterine death, IUGR, - Antibiotics, decr. poor fetal outcome,
congenital anomaly. vaginitis CARE OF PREMATURE NEWBORN;
Maternal Assessment of the infant; immediately after delivery is usually by means of the
Apgar score; The resulting Apgar score ranges from zero to 10.
Appearance,
Pulse,
Grimace,
Activity and Respiration. 4- Other method is amniotomy by plastic hook to break the membrane and
Resuscitation Medication After delivery, plastic wraps or rupture the amniotic sac. Within a few hours labor usually begins.
To reduce postnatal fall in Routinely give Vitamin K to warm mattresses to keep warm 12. Trophoblastic disease.
temperature include: prevent development of on their way to the NICU and Gestational Trophoblastic; Proliferative abnormalities originates from trophoblasts of
• skin-to-skin contact with haemorrhagic disease of neonatologic care. (NICU);
placenta
mother the newborn (HDN) premature babies are kept in
• drying the neonate Surfactant radiant warmers or
Classes; 1. Hydatiform Complete & Partial 2. Gestational Trophoblastic tumor
• radiant heater -immediatly after for birth in incubators. measurement of Hydatiform mole; Benign (Molar 2- Gestational Trophoblastic Tumor;
• covering the head + body or pregnant mothers with temperature, respiration, pregnancy) Malignant
with insulated material. threatened premature cardiac function, oxygenation, - Proliferation of placental - After molar pregnancy either mole or
For infant resuscitation delivery prior to 34 weeks and brain activity needed trophoblasts Distended uterus choriocarcinoma.
• radiant warmer Naloxone TREATMENTS; secrete hGG (like normal pregnancy)
• resuscitation bags and narcotic antagonist for IV fluids and nutrition, O2
masks neonate who is effected by supplement, mechanical vent. TYPES; Partial/incomplete Types; Metastatic;
• endotracheal tubes analgesics given to the Support, medications, kangroo Complete mole; mole; Non-metastatic; - Spread outside
• laryngoscope stethoscope mother before delivery care, breastfeeding, UV light for - %.90 (46xx); - Normal ovum + 2 - Persistant/ uterus
oxygen source and suction newborn jaundice empty ovum + sperm; (69xxx, invasivve mole - Lung, liver, Vagina,
• naloxone.
sperm 69xxy, 69xyy) - Confined to Brain.
- %10 (46XX)or CP; Abnormal uterus Dx; After evacuating
11. Prolonged pregnancy. Induction of labor (46xy);empty uterine bleeding, - Persistant inc. molar pregnancy
Post-term pregnancy (prolonged); >42 weeks ovum + 2sperm. Excess vaginal hCG + potentialy diagnosis made when
Etio; Complications;
CP: Especially bleeding, bleeding there is inc. hCG
- Error in calculation For mother; - Prolonged labor, labor distocia, severe
late first or 2nd Hyperemesis, TX; Almost %100 - Weeks/years after
- Nulliparty perineal injury, C-section, anxiety
- Previous post-term preg. Fetal; trimester; preclampsia, curable abortion/ectopic
- Obesity & male fetus -Stillbirth, meconium, aspiration - Heavy hyperthyrodism. - Single agent pregnancy inc. hCG
- Anencephaly - Shoulder dystocia , Macrosomia bleeding, - HCG not very chemo; (unless there is other
- Congenital adrenal -Sudden infant death syndrome uterine size high. methotrexate, pregnancy)
hypoplasia - Oligohydramnios more than Dx; US fetus + actinomycin D. TX;
Dx Management; options depend on; GA, maternal risk normal. hydropic villi -Hysterectomy Good
1-Gestational age (GA) factors, evidence of fetal compromise, maternal options - Hyperemesis - pathological prognosis ;single
calculation; may be unreliable 1- Induction of labour; usually 41-42w of gestation gravidarum, correlation + agent chemo.
due to irregular menses, - Bishop score >9, If ≤4 not favourable
preclampsia, cytogenetic - Bad prognosis; multi
inconsistent ovulation etc 2- Expectant management - Close surveillance
Naegele rule; date of mens - 3- Timing of delivery NST, CST + BPP
hyperthyrodism. analysis. agent chemo.
3m+7d 4. Intrapartum management FHR, Monitoring Dx; US (cavity Malignent
2-Early pregnancy US; to MONITORING; NST), BPP, AFI with small potential; <%5
determine GA; more relieble, BPP contains; fetal HR, breathinh, active vessicles instead extrauterine
also to see oligohydramnios movements, tone, Amniotic fluid volume. of gestational metastasis.
(AFI- indicate induction of Max;10 points sac & fetus. Dx; Lab hCG,
labor) - hCG level; > coagulation,
Induction of labor 100,000 miu/mL thyroid function
4 common methods of starting contractions; - Malignant CXR, pelvic US.
1- Stripping membrane (prostaglandin is naturally released and initiates potential; %2-32 Tx; Dilation +
contractions.) of cases currettage, IV
2- giving the hormone prostaglandin (ripens the cervix, and dilates) oxytocin (for blood
3- synthetic hormone pitocin. (most commonly Pitocin (IV)) loss),
Hysterectomy.
 Gravidarum tetani, Gravidarum Wernicke encephalopathy
13. Polyhydramnios and olygohydramnios osteomalacia, Gravidarum asthma. In Fetus; Growth restriction, Fetal death
Amniotic fluid; It is the fluid in the amniotic sac surrounding the fetus. Contains;
protein,urea,glu,UA,creatinine,lipids,hormones (insulin,prolactin,renin), Na,K,Cl 15. Preeclampsia and eclampsia.
Volume- varies according to the Color; normally colourless,at term becomes Preclampsia ; Eclampsia - life
gestational age pale straw
- Sudden onset HT >20w of gestation threatening
12 weeks – 50 ml Abnormal colours; green (infection), Golden
20 weeks- 400 ml yellow-due to presence of bilirubin, Prune + Proteinuria >0,3g/24h Eclampsia is a
36 weeks- 800ml-1 liter juice/dark brown- in presence of retained dead - Thrombocytopenia preeclampsia
At term - it reduces to apprx 700ml fetus - Inc. aminotransferases related seizures.
Measurement of AFI- Normal range is 5-24 cm, RF; first pregnancy, Multiple gestation, Mother >35yo, HT, Tonic-clonic
measured by US Obesity, DM, Family history. seisures w/o any
Patho; Spiral A. not dilate less blood to fetus; IUGR, death, neuro/metabolic
Polyhydramnios Olygohydramnios Cytokines vasoconstr.& kidney;  cause HT causes.
Defined as excess of amniotic fluid of more than Amniotic fluid is less than 200 ml Complications; placental abruption, liver and renal TX; ABC
2000ml or AFI> 25 cm or SDP>8cm at term or AFI < 5 cm OR SDP< 2 failure, DIC, Pulmonary oedema and CNS abnormality. Mg Sulphate +
Types: cm Mild preeclampsia BP ≥140/90 mm Hg and Proteinuria Diazepam HT:
Acute- sudden increase Etio; chromosomal >0,3g/24h. Labetalol
Chronic- gradual increase abnormalities, IU infections, in severe >5g/24h prot. w/HT >160-110mmHg) hydralazine
Etio; Idiopathic- seen in 2/3rd of the cases drugs (ACE inhibitors), renal HELLP Syndr. thrombi used up Delivery after
Fetal causes- Anencephaly, spina bifida, Fetal agenesis or UT obstruction, - Hemolysis, Elevated Liver enzymes, Low Pt stabilisation.
infections, Hydrops fetalis, Multiple pregnancy IUGR, Postmaturity - Also effect kidneys, retina, liver.
Placental causes; choriocarcinoma of placenta DX; Uterus is full of fetus - Effect endothelium→ Inc. permeability → Generalized, pulm, &
Maternal causes; DM,cardiac or renal diasese because of scanty liquor, cerebral edemaseisures eclampsia.
COMPLICATIONS; Malpresentation is common SX of preclampsia; Edema, headache, Visual symp. RUQ pain
During preg; preclampsia, malpresentation, Complications Dx; Urinalysis, renal / kidney function, coag. prophile. US, CTG,
PROM, placental abruption, preterm labor Fetal; Abortion, Fetal pulmonary BPP, Doppler.
During labor; PPH, cord prolapse, PROM hypoplasia, cord compression Tx; - Delivery, Supp. O2, medications; Acute→ Labetalol,
Puerperium; subinvolution, puerperal sepsis Maternal; Prolonged labour, hydralizine, Chronic methyldopa, Labetalol
FOR FETUS; prematurity and congenital Increased operative 16. Bleeding during second part of pregnancy
complications, death interference due to Antepartum haemorrhage (APH); bleeding from genital tract after gestation of
malpresentation potential viability (approximately 24 weeks). Common causes of APH include:
Placenta previa ; Placenta insert close Placental abruption; Premature placenta
14. Early toxicosis of a pregnancy. Hyperemesis to cervical os. seperates <37w of gest.
gravidarum. - Total completely cover cervical os. RF; trauma, previous placental abrup.,
Toxicosis; Occur due poisioning by fetal substances - Patial Cover partially Chronic HTN, smoking, preclampsia,
Early toxicosis (Gestosis) <12w Ptyalism Excess saliva, Dehydration - Marginal (low) Locate close to eclampsia, PROM, uterine inf., age >40.
RF; Age, Family EPH Complex (Edema, TX; Atropine cervical os around 2cm. Sx; external Vaginal bleeding,
Proteinuria, HT), Complicated gyne Nausea + emesis RF; Scar tissue due to; Surgery (C- concealed bleeding into uterus.
history,HTN, DM, Obesity, Multiple Light; 2-4/day, section), Multiparity, inc. Age, Previous - IUGR, Oligohydramnios, Coagulopathy.
gestation, Antiphospholipid Synd. Mod; 5-10/day, abortion, large placenta. Complications; Hypovolemic shock, Renal
Classification Severe; 20-25/day (H. Gravidarum) Sx; Painful bleeding after 20w, Partial, failure, DIC IUGR, prematurity etc.
- Due to term early & late H. gravidarum; also with dehydration, marginal may not show sx until delivery DX; US, CBC, Hb, Fibrinogen etc
- Due to Incidence weight loss, Ptyalism, Hematemesis Dx; Clinical, US Tx; Manage bleending, inc. fetal
Frequent; Nausea, Ptyalism, Vomiting. In mother; Liver, Renal failure. Tx; depend on bleeding, gestation, fetal maturation (corticost.), emergency C-
Rare; Hyperemesis, Dermatosis, Hyponatremia, Thiamine defic. condition, Corticosteroid, C-section, section.
 manage bleeding (bed rest, blood, IV - secondary  atropine, nebuliser, corticosteroid.
fluid)
17. Obstetrical coagulopathies. DIC Syndrome 18. Dystocia - definition, types and management.
Physiological hypercoagulation in -Platelets and coa.factors used up and Dystocia (Obstructed labour), even though Shoulder dystocia; after delivery of
pregnancy; cause bleeding and death uterus is contracting normally fetus does the head, anterior shoulder cannot
Elevated: fibrinogen, F VII, VIII, IX, X; Etio; amnionic emboli, not exit the pelvis during delivery pass below, or requires significant
Increased plasminogen; p.abruption/previa, fetal demise, ETIO; large or abnormally positioned baby, manipulation to pass. Diagnosed
Reduced plasmin activity; pre/eclampsia etc a small pelvis, and problems with the birth when the shoulders fail to deliver
Increased D-dimers; Tx; FFP, Cryoprecipitate, platelets, canal (narrow vagina and perineum which shortly after fetal head. It is an
Shortened PT, APTT recombinant activated factor Vll may be due to female genital emergency, and fetal demise can
DIC acquired syndrome, characterised by HELLP Syndrome; mutilation or tumors). occur due to compression of umbilical
systemic IV coagulation. Hemolysis, Elevated Liver enzymes,Low Apartograph is often used to track labour cord
Coagulation leads to; platelets progression and diagnose problems; RF; DM, macrosomia, and maternal
-Systemic activation of coagulation *Pt; <100.000microL combined with physical examination may obesity, but it is often difficult to
cascadefibrin deposits occur; thrombi *AST>70 IU/L, identify obstructed labour. predict
form in small/middle sized veins; cause LDH>600 IU/L Complications; Complication; fetal injury (such as
multiorgan failure and death; *Hemolysis baby; asphyxia and death. brachial plexus injury) or even fetal
mother; infection, uterine rupture, death
Shock; life threatening syndrome, emergency Stages of shock; PPH. Long term; obstetrical fistula. Management:
Cause; Imbalance btw O2 demant & supply - Stage 1 → Compensated; Dx; examination, US, prolonged labor Some maneuvers
- Hypoxia and Multiorgan failure Decr. BP & CO. Tx; Remove Tx; Maneuvers to reposition the baby, C- Episiotomy
Tx; Hemostasis ((Ca gluconicum,VitK,surgery..), O2 cause, IV fluid. section or vacuum extraction with possible Roll over on all fours
Infusions (crystalloid, Colloid, Blood etc), - Stage 2  Decompensated; surgical opening of symphysis pubis. Also
others(antib,corticosteroids etc) Organ functions effected keeping women hydrated and antibiotics if
1-Hypovolemick shock most common in (Clerebral, renal, myocordial) membrane ruptured for > 18 hours.
obs/gyne; hemorrage(Hypovolemia), diabetic - Stage 3  Irreversible; 19. Breech presentation. Mechanism of labor. Partial and
acidosis, diarrhae, peritonits SIRS, Sepsis Organ failure, Acute tubular total breech extraction.
Etio;p.abruption/previa/accreta, uterine rupture, perfusion impaired. Presentation w/ buttocks in lower part
atony etc Tx; ABC, resuscitation Etio; Dx; Abdo. exam Leopold maneuvr Partially assisted deliv.
2-Septic (Sepsis, endotoxemia); 2nd most Monitor; Pulse, BP, SPO2, Maternal Vaginal exam and US  show type of - Burns-Marshall Method
common, high mortality. RF; PROM, Endometritis, urine output, pH. - Poly/ breech. - Mariceau-smellie
Oligohydromnios Types; Complete, Incomplete (Footling), Method
Chorioamniositis, water delivery etc. Amniotic fluid embolism
- Uterus Frank - Prague Method
Tx; Correct hypovolemia, Delivery if possible, IV - Sudden CVS collapse, abnormalities Position = (LSA, LSP, LST, RST, RSA, RSP, - Punard Method
antibiotic. Cogulopathy during labor or - Space occupying DSA, DSP - Piper foreceps Method
SIRS t >36° or > 38°C, HR >90bpm etc post-partum period. lesion Delivery Complications;
Sepsis; SIRS + evidence of inf. - Amniotic fluid enter pulm, - Placenta C-section indications  - Cord prolapse
Septic Shock; sepsis + hypotension circulation. abnormalities - Large fetus - Birth trauma
3-Cardiogenic poor pump (Cardiomyopathy, Clinical; cough, sputum + - Multiparty - Hyperextended fetus - Asphyxia
arrhythmia) → Tx; Surgery, Resuscitation. blood, dyspnea, Cyanosis, Fatal - uterine dysfunction - Abdo organ damage
4-Distributive poor vessel tone peripheraly → pulm edema. - Prematurity - footling - Broken neck
- Multiple fetus - Previous perinatal death
Tx; ABC, Tx; ABC, Circulatory
- Fetal anomalies Vaginal delivery  Version;
 Spinal injury, anesthesia ABC, fluid, atropine mangement (vasopressor, IV - Fetal death - Spontaneous breech (rare) External cephalic version
5-Anaphylactic food, drugs, latex etc. fluid) - Short umbilical - Mechanism of labar Internal pedalic version
Tx; ABCD, Circulatay monopement, adrenaline, cord 1. Delivering of breech.
intubation, crystalloids. 2. Delivering shoulder/arm.
 3. Delivery head. Uterine packing / balloon tamponate, Surgery

20. Pelvic dystocia. Placenta accreta Synd.;

Female Pelvis is of four types. - Abnormal implanted placenta, Trophoblasts attach deeper Etio; Prior uterus surgery.
Types Of Female Pelvis (Caldwell-Moloy Classification) Classification; Placenta previa,
1 .Gynaecoid Pelvis; most suitable female 2. Anthropoid Pelvis; oval shaped inlet w/ - P. Accereta; attach myometrium Aggressive trophoblasts.
pelvic shape. This allow normal child birth large antero-posterior diameter and smaller - P. İncreta; penetrate to myometrium Dx; At time of delivery.
easily transverse diameter. It has larger outlet. The - P. Percreta; deep to myometrium & perimetrium, even bladder Tx;Hysterectomy
round pelvic inlet and shallow pelvic cavity problem is inlet. The diameters of inlet favors
with short ischial spines. All these feature the engagement of fetal head in occiput- 22. Cesarean section and pain management during
allow rapid birth of the baby posterior position that may slow down the delivery.
progress of labor. If head engages in anterior C-section; Delivering fetus via abdo. incision (loparatony) and uterine incision (hysterectomy).
position then labor progress normally mostly Indications; Types;
3. Android Pelvis; has triangular or heart- 4. Platypelloid Pelvis;has narrow anterio- CI normal delivery; Low transverse;
shaped inlet and is narrower from the front. posterior diameter of pelvic inlet. The pelvic - Placenta previa, Vasa previa - low adhesion risk,
It has prominent ishial spines and also has inlet is specifically kidney shaped. The pelvic - Previous classical C-section - low blood loss risk
narrower transverse outlet diameter. More cavity is usually shallow and diameters of - Previous myomectomy w/entering uterine cavity - May damage uterine vessels, cervix,
in tall women. Child birth is difficult and outlet are favorable for the process of labor. - Previous uterine reconstruction vagina.
more complicated. Women have to push But platypelloid pelvis don’t allow the head to - Fetal malpresentation - Requile bladder flap.
harder, walk more often and chances of engage. But if the head manage to engage - Active HSV infection Low vertical;
instrumental vaginal delivery are high. It may then rest of the process of labor may occur Dystocia or failed induction of labor; dystocia is - usually extend to contractile segments
prolong the labor. normally but in most of the cases it is longer obstructed labor. of uterine,
1. 2. 3. 4. - Cephalopelvic disproportion, failed descent - Gives more space
- Failed foreceps or vaccum delivery - Placenta previa
- Certain fetal malformations (hydrocephalus) - Malpresentation
Emergency conditions, immediate delivery - bladder flap needed.
- placental abruption w/ fetal/maternal Classical
comprimise - Longitidunal incision into anterior
- Umbilical cord prolapse fundus
- antepartum/intrapartum hemorrhage - Rarely used In cervical Ca, Myomas.
- Intrapartum fetal acidemia w/scalp PH <7.2. - No bladder flop.
- Uterus rupture - Adhesion risk
21. Bleeding in placental and postplacental period. - Bradichardia - Hard closure, inc. blood loss.
Postpartum haemorrhage (PPH)sudden, dramatic and life threatening and is an obstetric PROCEDURE;
emergencies. Primary PPH; loss of >500 ml of blood from the genital tract in first 24h after the 1- Anaesthesia; Regional; Spinal, Epidural. 3- Delivery of infant; Vertex or breech,
delivery. Secondary PPH is btwn 24 h and 6 weeks postpartum Sometimes general; inhalation vacuum or forceps may be used, Placenta
Causes of primary and secondary postpartum haemorrhage: 2- Surgery; removed or delivered spontaneously.
Primary: Uterine atony (common), Cervical or Vaginal lacerations, Uterine tear/rupture – (very a. Abdo incision; Pt in lateral tilt; 4- Wound cloure; Exteriorise uterus, massage
rare),Coagulation disorders. - Midline incision fundus, inspect
Secondary:Retained products of conception, Infection. - Pfannenstial incision more time, more - Clean uterus cavity
Obstet. Hemorrhage; Hemostasis; by myometrial contractionsCompressing vessels. esthetic result. - Uterotonics for contraction of myometrium.
UTERINE ATONY; Failure of uterus to contract UTERINE INVERSION; b. uterine incision → selected due to - Close incision
- After placental deliveryPalpate fundus to ensure Etio; Fundal placentae development of uterine segment, - Peritoneum of Bladder reflection not need to
contractions If not vigorous fundal massage & atony, abnormal placenta presentation of infant, placenta location. close.
oxytocin infusion. (accereta) - Bladder flap created to excess lower - Close obd. incision
RF; Primiparity, high party, overdistended uterus, TX; uterine relaxation segment. Seperation of bladder from lower Complication; Endometriosis, UTI, wound inf.,
Induction of labour w/oxytocin/prostoglandin agents, puting it back than segment by incising vesico-uterine serosa. Thromboembolic events, Hysterectomy,
Uterine rupture.
Tx; uterotonic agents, Bimanual uterine compression, uterine contractily agents.
 Hepatomegaly, hyperkalaemia,
23. Operative vaginal deliveries – forceps and vacuum. hypoglycaemia, and acidosis.
Operative vaginal delivery; Applying direct Requirements;
traction an fetal head w/ foreceps or vacuum - Fully dilated cervix Dx; All of the following must be
Indications; To Shorten 2nd stage - Ruptured membrane 1. Before birth present to say asphyxia;
* Non-reassuring fetal status - Position, station must be NST, BPP, US and Doppler US- placental -Metabolic or mixed acidemia
- Based on; HR, auscultation, lack of Scalp known circulation ,Ultrafast fetal MRI (pH <7.00) in umbilical A. blood
stimulation or scalp pH. - Head must be engaged, Cardiotocography,Fetal echocardiogram sample, -Apgar score 0-3 for >5
* Prolonged second stage - Apropriate pelvis Fetal movement counts min.
- Nulliparous >2h w/RA or >2h w/o RA - Empty blodder Doppler velocimetry-direction and characteristics -Neonatal neurologic sequelae
- Multiparous >2h w/RA or 1h W/o RA - Anesthesia of blood flow (eg, seizures, coma, hypotonia).
* Certain maternal illness heart disease, CI; Non-vertex 2. After birth Moderate Apgar score is 4-6 at
a. Apgar score the first minute. “Blue
pulmo. Compromise. - Non-engaged presenting part
b. Umbilical cord gas pH asphyxia”.
*Poor voluntary expulsion efforts due to - Prematurity, fetal bleeding
c. Neuroimaging- to determine time of injury Severe birth asphyxia −Apgar is
exhaustion, anesthetics, muscular disease disorder, Some drugs.
Apgar score <6 on 5th minute; permanent 0-3 at the first minute. “White
FORECEPS VACUUM EXTRACTORS damage of the CNS asphyxia”.
- Two matched blodes with suitable Device with cup, hose, vacuum device Management D= Drugs: Adrenaline .01 of .1
shape of fetal head & vaginal canal. - Malmstrom vacuum extractor. intrauterine resuscitation or operative delivery solution
Classification; - Plastic cup extractor. • A= airway: Suctioning, if necessary Hypothermia treatment to
- Outlet (visible scalp) Complications; endotracheal intubation reduce the extent of brain injury
- Low (at least +2 station) Maternal; loceration of; cervix, • B=Breathing: PPV, bag and mask, or through Epinephrine 1:1000
- Mid (above +2 but engaged presented vagina, perineum, bladder, endotracheal tube (0.1-0.3ml/kg) IV
part) Hemorrhage, hematoma, Coccyplal C=Circulation: chest compressions and Saline solution for hypovolemia
- High (Not performed anymore) fracture, episiotomy. medications if needed
Stations; -3,-2,-1, 0+1+2+3 Fetal; Scalp abrasions, locerations, Hemolytic disease of the newborn (erythroblastosis fetalis)
- 0  Biparietal diameter is in ischial Soft tissue injury, Cephalohemato, Develops in a fetus, when IgG of mother pass DX;
spine Subglial hemorrhage, Intracranial placenta, attack fetal RBCs, causing hemolysis. 1. Rapidly progressive severe
hemorrhage, Facial n. Injury. Etio; Rh-negative mother to Rh-positive fetus) hyperbilirubinemia
RF; placental abruption, abortion, after 2. Positive maternal antenatal antibody
24. Asphyxia of the fetus and newborn. Hemolytic disease cesarean and ectopic pregnancy. Procedures 3. Positive direct Coombs test (direct
of the newborn. such as amniocentesis, chorionic villus antiglobulin test)
Perinatal asphyxia; respiratory failure in newborn, due to inadequate intake of sampling, and cordocentesis also increase risk 4. Hemolysis on blood film findings
oxygen before, during, or just after birth. Sx; Jaundice- at birth or in the first 24 h after Management
Two main types of neonatal asphyxia: birth w/rapidly rising unconjugated Br, Anemia RhIG (within 72 h of delivery) Better to give
Acute asphyxia– due to intranatal Chronic Asphyxia,due to placental 3. Hepatosplenomegaly all unsensitized Rh-negative women at 28w
4. Fetal hydrops in severe cases- from fetal gestation, booster after birth
factors only. insufficiency.
hypoxia, anemia, congestive cardiac failure, and 2-Phototherapy
RF; C-section, Malpresentation RF: Maternal age, Prolonged (> 8 day) hypoproteinemia secondary to hepatic 3- IVIG (Anti-D Ig)
Premature or retarded birth, pregnancy.Preeclampsia, Multiple dysfunction 4-Exchange transfusion; if Br is >4 (cord Br)
accelerated labor, placental abruption, pregnancy, DM, Smoking or drug addiction,
forceps or vacuum, Congenital IUGR etc Sx; Before delivery; Abnormal HR
malformations, hypoxia in mother or rhythm − Increased movements of fetus
(shock, amniotic fluid embolism, At birth: Physiological reflexes are
Maternal anesthesia depressed,Hyperesthesia. Meconium in
amniotic fluid, rales over lungs
 Hypocalcemia,Hyperbilirubinemia Insulin
- Maternal effects - 3rd trimester
25. Fetal distress - methods for evaluation.
- Preclampsia Evalute glysemic cortal, Insulin, Delivery
Diagnosis of fetal health Non-stress Test (NST), Fetal HR, (BBP) Biophysical - Diabetic neuropathy, retinopathy, nephropathy planned at 38
1. Naegele's rule (Mens acceleration w/ movement. prophile; Series of - Ketoacidosis, infections Dx; 2h Oral Glu Tolerance Test
+3m -7d) 1-Reactive; 2 acceleration, at tests; NST, Fetal Type 2 can also be seen. Gestational DM; Due to changes 1h post glu >180mg/dL
in Glu metabolism in pregnancy.Same w/ normal DM 2h post glu >153mg/dL
2. Quickening (Fetal least 15 beat in 15 sec breathing, Fetal
Fasting >92mg/dL
movement around 16- amplitude in 20min. toore, Fetal motion, TORCH Syndrome Rubella; virus, 1st trimester %90, After 18w not
20w) 2-Non-reactive; Usually due to Quality amniotic Toxo; Parasite serious, Sensorineural deafness. CV anomalies.
3. Uterus size (12w iliac fetus sleeping. Longest should fluid. Sx; - Asympt., LAP, flu Cataracts Also: microcephaly, jaundice, meningo
-Sympt. encephalitis etc.
crest 20w umbilicus etc). be 40 min. Inactivity. If - Max 10 point
Newborn (3C) Calcification, Hydroceph., CMV; Similar to toxo
4. Doppler Us Heart >40min BPP, CST - AFI ; Amniotic fluid Chorioretinitis. Tx; Ganciclovir, Valganciclovir
sound 10-11w. Contraction Stress Test (CST); - index If <5 IUGR, Hepatospl. megaly, jaundice etc. HSV; While in birth canal; HSV-2
5. US Crown-Rump ve, +ve, equivocal oligohydramnios. Tx; Spiramycin pregnant. Pyrimethamin Hydrops fetalis, vesicles ulcer, eye damage.
Sulfadiazine neonate TX: Acyclovir, Valacyclovir
Length 1. -ve 3 uterine contractions
CV Disorders; Thyroid Diseases;
Biparietal moderate intensity. last 40- APGAR Score; Rheumatism; - Hypo; Levothyroxine
diameter 60sec in 10 min w/no late Appearance, GRABHS - Hyper; Can cause many complications, Anti
Femur length decelerations in FHR. Pulse, Mitral defect; thyroid grugs
Abd. 2. +ve >50%. late Grimace, - MS-> Commisurotomy, C-section Cause neurodevelopmetal problem,
- AS if severe Valve replacement Deafness, mortality etc. Spont. abortion
circumference deceleration associated w/ Activiy, - MI Abortion, early delivery Lung Disease
Bishop Scoring Scale To contractions. In IU Death, low Respiration. - AI pregnancy not acceptable - Pneumonia, Active TB

- Delivery recommended.
assess induceability, APGAR, IUGR, etc Arterial HTN
Dilation, Effacement, - Systolic >140, Dias >90
Complication; Preclampsia, IUGR
Consistency, Station, 3. equivocal inconsistent late
27. Ultrasound in obstetrics.
Position. declaration.
Basic obstetric US; Characterizing pregnancy location, identifying the no of embryos,
Fetal Distress; prenatal diagnosis of fetal anomalies, estimating GA etc
Fetal hypoxia that RF; Dx; CTG, NST, US. It can also diagnose an extrauterine pregnancy or an abnormal pregnancy, such as a
cause fetal disturbed fetal blood flow - Fetal scalp blood hydatidiform molar pregnancy, an anembryonic gestation or an incomplete versus
damage - Can be - Preclampsia, eclampsia sample complete abortion.
acute & chronic - endocrinopathies, HT, nephritis - Amnioscopy, TYPES; TV or TA and can use different modalities, eg Doppler, perform fetal
Signs; Decr. fetal - Prolong/Preterm pregnancy amniocentesis
measurements. It is also used to perform different procedures, eg amniocentesis.
movements - Placental insufficiency Tx; Amnio fusion, In first trimester Second and third trimester
- Abnormal NST uterine, pelvic, adnexal factors Tocolysis (to • Typically performed Use fetal biometry to assess fetal growth and also can provide
or CST, BPP - Narrow pelvis, ovarian dysfunction, prevent to confirm a viable detailed information on fetal anatomy.
- Abnormal fibroits Cancer cysts prematurity) intrauterine pregnancy. Standard obstetric US also may include an evaluation of fetal
amniotic fluid. Maternal anemia, TB, mental disease Possible to be TA or TV; presentation(s), amniotic fluid volume, cardiac activity, and
- Vaginal Placental problems ideal before 13w and placentation.
bleeding, cramps. - Abnormal position/presentation of 6d of gestation. Fetal biometry; measures the fetus' biparietal diameter, head
- Inc. BP, fetus • - US TV or TA , circumferences, abdominal circumference or average abdominal
Sac; 5W, Yolk sac; 6W , diameter and femoral diaphysis length.
insufficient - IUGR, Macrosomia, multiple pregnany,
Fetus; 6-7W, Heart Assessment of fetal anomalies, also known as a fetal anatomic
weight gain Premature rupture
beat; 7W survey, should be performed after 18 weeks gestational age and
26. Pregnancy and extragenital diseases. ALSO; accurate ideally performed between 18-20 weeks gestational age.
* Pregestational DM; Management gestational age The basic fetal anatomic examination includes assessment of the
Type 1 or Absolute insulin def. - 1st trimester
assessment following structures: lateral cerebral ventricles, choroid plexus,
- Fetal effects; Spontaneous abortion or Preterm delivery, Monitor glucose, Insulin TR,Diet
Malformations, Cardiomyopathy, Fetal - 2nd trimester midline falx, cerebellum, cistern magna, upper lip, four-chamber
demise,Macrosomia, Hypoglycemia, screening AFP for tube defects, Fetal echo, view of heart, size and location of stomach, urinary bladder and
 ureters, spinal anatomy, extremities, and gender. Midcycle spotting -spotting just before ovulation. Due to a decrease estrogen
Postmenopausal bleeding - bleeding after at least 6 m/ 1y of cessation of periods.
Amenorrhea - no uterine bleeding for 6 months or longer
Gynecology Dysmenorrhea Premenstrual Syndrome (PMS)
28. Menstrual cycle - hormonal and clinical characteristics. Pain, cramping associated with menstruation (back Recurring psychological and/or somatic
Menarche: Age at onset of menstruation The menstrual cycle depends on cyclic ache, nausea). Due to prostaglandin production at symptoms during the luteal phase of the
Primary amenorrhea: No menstruation production of estrogen and progesterone to menses cycle, relieved by onset of menstruation
despite signs of puberty regular occurrence of ovulation throughout a TYPES; - Primary - Frequency; 95% of women report mild
Secondary amenorrhea: No mens for 3-6 woman’s reproductive life. Normal menstrual - Secondary symptoms, 5% severe symptoms
months in a woman who previously cycle = 21 to 36 days - Chronic pelvic pain disrupting normal life
menstruated Characteristics of the menstrual cycle - Frequency:30-60% of women report symptoms - Etiology:Unclear, appears to be an
Dysfunctional uterine bleeding: Irregular - Rhythmic appearance -at equal intervals. - 7-15% interfere with daily activities abnormal response to hormones
bleeding due to anovulation or anovulatory - Blood -dark, not clot and has a specific odor. - More frequent among < 25 years (67-72%) - Treated with selective serotonin-
cycle - Amount of bleeding - 30-50 ml. - Decreases after pregnancy and with use of oral reuptake inhibitors (SSRIs)
Oligomenorrhea: Menstrual interval >35d - Menstruation(definition)- mucous-bloody contraceptives
Polymenorrhea: at short intervals (<21d) discharge from the uterus, due to loss of the - Treatment: oral contraception; NSAID drugs
Menorrhagia: Regular menstrual intervals, endometrial mucosa prepared for implantation. Amenorrhea Menorrhagia; Excessive menses but
excessive flow and duration Normal Menstruation - Primary lack of menses by age 16 normal cycle:
Metrorrhagia: Irregular menstrual 9 years  Menarche age 12 16 years - Secondary cessation of menses for > 3 months ETIO;
intervals, excessive flow and duration - Highest rate of anovulatory cycles <20 or >40 - Most common cause of secondary amenorrhea is Painless; Fibroids (leiomyoma),
Anovulation/anovulatory: Menstrual cycle yo PREGNANCY Coagulation defects (rare), Endometrial
without ovulation - Duration of flow 2-8 days Secondary Amenorrhea; Absence of ovulation, cancer or Endometrial polyp
Mittleschmertz: Pain with ovulation - Amount of flow dependent on how rapid progesterone deficiency, Inadequate growth of Painful:PID, endometriosis,
Molimina: Symptoms preceding menses endometrium sheds endometrium due to low estrogen adenomyosis, etc
Dysmenorrhea: Menstrual cramping/pain - Incomplete shedding = heavier flow, blood loss H-P-O axis dysfunction; Alteration in pulsatile Menses may be w/short interval (<21d),
anemia GnRH secretion or excessive menses w/ long intervals
Neuro-hormonal regulation of menstr; by sex hormones - Diagnosis of exclusion, Multiple causes; exercise, (anovulatory ovarian disorder due to
phases of menst. Cycle; weight, stress, medications, tumor prolonged estrogen disorder)
Ovarian Failure Causes may be; thyroid problems,
1- Follicular phase; (1-14d)
- Menopause excessive stress or exercise
- FSH stimulate development of follicles in ovaries estrogen production Supress - Premature ovarian failure; Autoimmune, Metrorrhagia & Menometrorrhagia
FSH dominant follicle selected LH surge ovulation. chemotherapy • Ovarian insufficiency
2- Luteal phase; (14-15d). - Gonadal dysgenesis (Turner’ s syndrome) • Myoma, endometrial
- ovulation dominant follicle rupture oocyte released LH stimulated dominant - Androgen insensitivity cancer/hyperplasia, cervical ca.
follicle become Corpus luteum inc. Progesterone if no Pregnancy Corpus luteum Outflow Obstruction Leading to Amenorrhea Oral contraceptive use
regres. - Imperforate hymen, Absent uterus/vagina, Intermenstrual bleeding
3- Menses; (3-7d) Menstrual bleeding, (around 14d after ovulatien). Asherman syndrome Neoplasia: Cervical, Uterine,
Dx; History, PE Endometrial, Ovarian cancer
4- Proliferative phase; Growth of endometrium via presence of estrogen
- Labs; Rule out pregnancy Endometrial abnormalities:
5- secretory phase; (10-14d); Functional layer of endometrium is prepared for
- Diagnostic studies; USN, MRI, MRI of sella turcica Endometriosis, Adenomyosis, Uterine
implantation by influence of progesterone. - Progesterone challenge leiomyomas, Endometrial hyperplasia,
29. Menstrual abnormalities. Treatment; Diagnosis dependent Polyps
Menorrhagia - prolonged (>7days) or excessive (>80ml/day) bleeding at regular - Hormonal , - Behavioral Drug induced: Use of progestin-only
intervals - Surgical reconstruction; Neovagina contraceptives
Metrorrhagia - bleeding in irregular intervals and/or more frequent intervals - Non-surgical reconstruction; Vaginal dilators Inflammation: Cervicitis, Endometritis,
Menometrorrhagia - prolonged or excessive bleeding occurring at irrregular and STD
Endocrinological causes: Hormone
more frequent intervals imbalance,
Intermenstrual bleeding - bleeding of variable amounts between menses PCOS,
 Related to pregnancy: Ectopic uterine fibroids, mammary tumor pathology and signal vaginal or cervical cancer.
pregnancy (Incomplete) dysfunctional uterine bleeding.
30. Dysfunctional menstrual bleeding: aldolescent
(metropathia haemorrhagica juvenilis); climacteric Adolescents 2-PCOS: most common cause of irregular
(metropathia haemorrhagica climacterica). 1- Ovulatory dysfunction; most common cause menses, oligomenorrhea, or amenorrhea,
Etiology • HCG, CCB, coagulation of AUB in adolescents; cycles are not associated with hyperandrogenism.3-
• Systemic disease: thrombocytopenia, hypo or profile, hormones consistently ovulatory for the first few years Intermenstrual bleeding (metrorrhagia),
hyperthyroidism, cushings, DM. • US (External, Transvaginal after menarche, especially if menarche occurs bleeding btwn periods. Common causes in
• Pregnancy & hysteroscopy)- check for at a later age. adolescents;
• Trauma to vulvula, cervix or vagina endometrial thickening, During this time, the most common cause of • Pregnancy
• Carcinomas fibroid changes, PCOS, irregular menstrual cycles is immaturity of the • STIs
• Structural disorders: ovarian cysts, cervicitis, endometritis, pregnancy,etc HPO axis, also pregnancy, PCOS, • latrogenic etiologies from administration
salpingitis - Sonohysterograhpy hypothyroidism, hyperprolactinemia, and of exogenous steroids, including oral
• PCOS due to excess estrogen • MRI/CT- if there is functional hypothalamic dysfunction contraceptive pills
• Oral contraceptives and IUD's recurrent bleeding 31. Vulvovaginitis.
• Abnormal C-sec scar- isthmo-cele that causes delayed • Endometrial biopsy and Vulvovaginitis; Inflam of vulva + vagina
menstural bleeding sampling 1- Bacterial 2- Candida 3- Genital 4- Contact
Sx; complains of uterine bleeding disorders. Treatment: Vulvovaginits - Vulvovaginits Herpes vulvovaginits
Dx; Take reproductive history: Age of menarche, Mens history 1. Hormonal replacement Multiple sex partners - Acquired mostly - HSV-1 & HSV-2 - Due to exposing to
and regularity, duration, Postcoital bleeding etc 2. Curettage Agent; Gardnerella sexually or mostly allergen by
• Check for anemias. DM, thyroid diseas, endocrine anomalies, 3. Abrasion of endometrium vaginalis, Mycoplasma colonisation in genital Sx ; Inguinal LAP, vaginal/vulvar
weight loss 4. Ablation of endometrium hominis organs. severe pelvic epithelium (perfume,
• Inspect vagina, cervix and rectum. (recto-vaginal 5. Hysterectomy CF ; Homogenous, - Mostly Candida pain, dysuria, dye, tampon, pad)
examination to check cul-de-sac, post-uterine wall and utero- white, non-inflam albicans urinary retention, Sx; swelling, itchy,
sacral ligaments) [too find the source of bleeding] discharge. RF ; loss of normal etc ulceratian.
- Presense of clue cells flora, antibiotics, Inc. - Also; fever, Tx = Resolve
Climacteric; Anovulatory bleeding in menopausal Dysfunctional uterine bleeding - PH >4.5 vaginal pH malaise, If severe:
transition due to declining ovarian follicular (Metropathia haemorrhagica - Bad odor dischage Sx ; leucorrhea, headache, antihistamins, topical
function. climacterica); Cause is anovulation; - Also fishy odor after Severe vaginal myalgia steroid.
• Estradiol levels will vary and bleeding might be leads to proliferative and hyperplastic adding KOH prunitus, Unusual - Vesicles, painful
light or heavy processes in the endometrium. Complications in odor, Vulvar heal 21days
Due to FIGO, climacteric phases are; Hyperplasia peak of about 47-48 yo and Pregnancy preterm erythema, Vaginal Dx; PCR, culture,
1. Warnings (premenopause); phase of decrease malignant potential is 25-30%. labor, PROM. erythema, Thick Pap smear
ovarian activity. Characterized by; hypotension, • Endometrial atrophy (thinning of the *Also cause PID, cottage chese Tx; Not curative,
irregular mens and dysfunctional uterine bleeding. uterine lining): Low hormone levels endometritis, etc discharge systemic antiviral.
Duration 4-6 to 10 years. after menopause can cause it to get too Tx ; Metronidazole Tx; Topical azoles,
2. Menopause; time from last uterine bleeding, no thin,cause bleeds oral diflucon
menstruation occurs for 1y • Endometrial hyperplasia (thickening): 5- Trichomonas 6- vulvovaginits in 7- Vaginal foreign 8- Atrophic
3. Postmenopause; phase linking the last After menopause, too much estrogen vaginalis Protozoa, HIV seen more in body vaginitis
menstruation to the last stage of life; senium. and too little progesterone. As a result, STD HIV pt. - If stay >48h - During menarche,
Gradually complete or almost complete the endometrium gets thicker and can - cause adverse cause infection pregnancy, lactation,
discontinuation of ovarian function. Duration is 6-8 bleed. pregnancy outcomes (E.coli, or aerobs) post menopause
years. • Vaginal atrophy; After menopause, Sx; Greenish froathy CP; Foul smelly (lack of estrogen).
In only 20-25% of women, the climacteric is due to low estogen walls to become vaginal discharge discharge Sx; Sore, spotty
asymptomatic, others over have different type and thin, dry, and inflamed, leads to - Pruritus, dysuria, Tx: Remove discharge
severity symptoms bleeding after sex. strawberry cervix foreign body, 9- Pinworms E.
Pathology of the premenopausal phase; • Cancer: Bleeding is the most common Dx; Microscopy, Antibiotics vermiculos
diabolation and anovulation, with a rapid increase symptom of endometrial or uterine culture.
in the incidence of premenstrual syndrome, cancer after menopause. It can also Tx; Metronidazole
32. Precancerous and early cancerous lesions of the cervix.
Cervical intraepithelial neoplasia (CIN) is a premalignant condition of the cervix.It is usually 34. Endometrial cancer.
asymptomatic and is detected by routine cytological screening. The degree of severity is graded Endometrial Ca; - 75% post menapausal women
CIN 1 to CIN 3. RF; Prolonged estrogen Endometrial Ca; Uterine
Etio; HPV (most commonly 16,18) adequate cytology and exposure. Sx; Irregular menses Sarcoma SM
RFs; Intercourse young age. colposcopy follow-up needed - Early menarche - Post menapause bleeding of uterus
- Conception young age. TR; depends on the degree of - late menopause - Pelvic pain - Endometrial
- Multiple partners dysplasia. - Obesity Stages; (FIGO staging) stromal
- Previous STDS Mild dysplasia (LSIL or CIN I) -PCOS 1- A- tumor in endometrium - leimyosarcoma
- Smoking, immunosupression may go away without - Exogenous estrogen B- Invade half of myomatrium - Adenosarcome
Screening same as cervical Ca treatment.follow-up by Pap - Tamoxifen 2- Involve cervical stroma not extend etc.
Dx; Pap test smears every 6-12 month - Estrogen secreting beyond utenes
- Colposcopy acetic acid turn abnormal Moderate-to-severe dysplasia tumors. 3- local or regional spread
white or mild dysplasia that does not - Breast, ovarian Ca A- serosa, adnexa
It is grouped into three categories:::: go away may include: Endometrial B- Vagina, parametrium
CIN I -- mild dysplasia- Confined to basal 1/3 of Cryosurgery, Laser therapy, Hyperplasia; causes C- Pelvic / paraaortic LN
the epithelium LEEP (loop electrosurgical type 1. 4- A Bladder, rectum
CIN II -- moderate to marked dysplasia; confined excision procedure), Surgery; - Precursor of Ca; - B- Distent metartaris
to basal 2/3rd of epithelium cone biopsy or Hysterectomy Simple w/o atypia & Dx; Biopsy, CT, TV US
CIN III -- severe dysplasia to carcinoma in w/ atypia If advanced; Cystoscopy,
situ…..extend beyond 2/3 of epithelium - Complex w/o atypia Sigmoidoscopy,Pelvic and Abdo CT
33. Cervical cancer. & w/ atypia 29% risk Tx; Surgery Total abdo
RF; Intercourse young Etio; HPV 16, 18 high Stages; confine cervix of Ca. hysterectomy
age. risk 1- a- <5mm  Type 1; - Bilateral salphingo oophorectomy +
- Conception young age. Sx; Bleeding btw b- Visible macroscopically Adenocarcinoma, Pelvic/aortic LN
- Multiple partners periods. around 4cm Estrogen dependent Stage IB or less: total hyst/BSO/
- Previous STDS - Abnormal mens 2- a- w/o parametrial  Type 2; Papillary, adjuvant pelvic XRT
- Smoking, bleeding invasion serous, clear cell. Stage IC to IIB: total
immunosupression - Pain or bleeding after b - Spread into tissue around not depend to estrogen hyst/BSO/adjuvant pelvic XRT
Screening intercourse or pelvic cervix Stage III: total hyst/BSO/adjuvant
1. Age 21-25 exam 3- extend pelvic wall, involve chemotherapy
2. Age 25-49 - Inc. Vaginal discharge lower 1/3 of vagina may Stage IV: palliative XRT and
3. Age 50-64 - Persistant pelvic/back cause hydronephrosis chemotherapy, Hormonal tr
4. Age +65 pain 4- extend to other organs

& Liquid cytology

Pap test Conventional Dx; Pap test a- rectum, bladder
- Colposcopy acetic b- Distant metastasis
Results; Pap acid turn abnormal Tx; - Surgery Cone biopsy,
classification & Bethesda white Radical hysterectomy.
system - Cystoscopy, - ChemoCisplatin,
proctosigmoidoscopy, Paclitaxel
etc. - Radio external, Interal
Prevation vaccine
35. Myoma 37. Ovarian tumors - basic characteristics.
Uterine myoma; (Fibroids, Leimyoma)- Proliferative, well circumscribed, General characteristics; CP; Asymptomatic
pseudoencapslated benign tumor of SM & fibrous tissue. - Mostly benign, 5-15% of - Bloating, abd. discomfort, menst. problems
Etio; Single neoplosm Dx; Physical exam. 3- Surgery ; all gупеcological diseases - Felling of weight in pelvis
- Chromosome - chronic anemia Myomectomy - Free growth in abdo - Compression symptoms; Urinary retention,
abnormality, Estropen, - Abdo exam: Nodular tumors - Abdominal
progesterone - Pelvic exam: uterine enlarged - Hysteroscopic
cavity, reach lage sizes w/o Hydronephrosis, Obstipation
- Local factors, EGF (asymmetric & irregular) - Laparascopic clinical symptoms Complicatiion; Torsion, Rupture, hemorrhage,
Classification; - Speculum: Fibroid polyp. - MRI guided focused - Round shape ischemia, necrosis, infection, malignant
Intramural, Submucosal, - Labs; Hb +HCT anemia, Coog. - Cryomyolysis - Can grow degeneration, 2ndary adhesions.
Subserosal prophile + bleeding time - Uterine artery occlusion intraligamentary (brood Dx; Anamnesis, Gyne exam, US, MRI, Laparascopy
Characteristics; Size, - Imaging; US for location + size, Complications lig), & compress ureters Tumor mokers ; Ca 125, Ca 19-9, AFP, Inhibin, B-
Shape, Color, Sonohysterography to see 1. Degerivative; hyaline
Consistency, Capsule pedunculated submucosal degeneration, fatty
hydronephrosis HCG
(Pseudocapsule) Sx; leimyomas, Hysteroscopy, MRI degeneration, Calcification,
Asymptomatic Tx; Red degeneration, Atrophic 38. Benign ovarian tumors.
- Dysfunctional uterine 1- Expectant management ; change, Myxcomotous - Normally diagnosed while investigation of chronic pelvic pain or an abdo mass.
blading - bimanual exams (every 3-6m) change, Psoudocystic. Types;
- Excess, prolonged - Endometrial biopsy 2. Vascular; Torsion,
1- Functional 2-Inflammatory 3- Germ cell 4- epithelial 5- sex cord
bleeding, anemia - Repule blad counts Telangiectasis, congestion
- Pain may be torsion, - NSAIDS & edema.
- Folliculor -Tubo-ovarian - Benign 1. Serous stromal
infarction. - low dose oral contraceptives 3. Inflammatory cyst -Endometrioma teratoma cystadenoma ; - Fibroma
- Pressure Pelvic 2- GnRH Agonist ; create 4. Malignant - 4-5am -Associated (dermoid) 25% of cases, 20% - thecoma ;
heavyness pseudomenapause. - Incorrect W/PID in young - Common 20- bilateral, single smooth gray
- Reproductive uterine women 40yo. chamber, 5-15cm, surface,
problems infertility, bleeding - hair, teeth, translucent, fluid
endometriolic secrete
ectopic pregnancy. - Spontaneous fat, skin etc. filled, originate
cyst; estrogen
resorbtion - 10% of all from epithelium.
36. Endometriosis - Chocolate cyst menapause,
- Corpus ovarian 2. Papillay
- Presence of functional endometrial glands and stroma outside their usual location in - Due to ovarian
luteal cyst tumors. cystadenoma ; 40- bleeding.
uterine cavity. endometriosis - 5-10 cm 60 yo., cyst w/ - Mostly in
- Theca cyst
Etio; Retrograde menstrual flow Some abnormal locations; Thorax, nasal - Has capsule - Anterior to papillary growth elderly 50-
- not grow
- Hematogenous & lymphatic passages, brain, umbilicus, surgical icision. >10cm - Limited uterus inside capsule, 5- 60yo
spread. Dx; Markers Inc. CA 125 - simple mobility - 15% bilateral 30cm, epithelial
- Genetic immune factors. - Pelvic exam and imaging (US, MRI) unilocular cyst - lined by origin.
Sx; Dysmenorrhae - Laparoscopy Brown pigmentation, in US keratinised 3. Mucineous
Squamous cystadenoma ;
- Ovulation pain (unilateral) fibrosis, Atypical lesions. epithelium &
- Chronic pelvic pain (>6month) Tx; Expectant; NSAIDS largest, filled by
has sebaceous
mucinous
- Infertility - Medical (Oral contraceptives, progestins, & sweet
content.
- Urinary symptoms (frequency, GnRH agonists, danazol, aromatase glands.
urgency, etc) inhibitor) - commonly
- GIT symptoms (nausea, vomiting) - Surgical; Conservative, Radical contain hair +
fat secretion
39. Malignant ovarian tumors. - 2nd most common gyne malignancy. 41. Acute abdomen in gynecology.
Epithelial ; 90% Non-epithelial *Rapid onset severe symptoms that indicate potentially life threatening intra-abd
1- Surface epithelium 2- Sex cord stroma; 3- Germ cells; Dysgerminoma pathology
stroma; Serous, Mucinous, Granulosa cell 90% most malignant, Yolk sac, Sx; abd. pain, vomiting, rigid abdo, meteorism, Dx; History
endometrioid, Clear cell, curable, Thecoma, Embryonal Carcinoma rare, shock Physical exam; Unstable
Transitional cell. Fibroma, Sertoli cell, young women, Choriocarcinoma,
Sertoli-Leydigcell, steroid. Thecoma.
Gyne causes; vitals
1- Intra Abd. bleeding; Ectopic pregnancy, - Abdo tenderness
EPITHELIAL Ov. Ca
- Difficult to diagnosis Staging; Ovarian hemorrhage - Masses
- Non-spesific symptoms 1- limit with ovaries 2- Acute decr. of Blood supply of genital organs; - Peritoneal signs
(distention, lower abd. pain, pelvic 2- Involvement of one/both ovaries w/pelvic extension Ovarian torsion, Adnexal torsion - Pain
mass, weight loss. a-  Uterus/tubes 3- Inflam. diseases of internal genitalia; Pelvic exam; inspection
RF; family history, BRCA 1, BRCA 2 b-  bowel/bladder - Acute salphingitis, salphingo-oophoritis, tubo- - speculum exam
mutation, low party, infertility c-  2a/2b w/ascites containing malignant cells
ovarian abscess, rupture - Bimanuel exam
*Oral contraceptives decr. risk of ruptured tumor capsule
ovarian & endometrial Ca. 3- One or both avaries w/peritoneal metastasis outside
- Pelvo peritonitis Tests; Urine, blood, imaging
Dx; Early Dx is rare, may be in pelvis or liver metastasis or + retroperitoneal LNS - Parametritis (US, CT, MRI)
bimanual exam. 4- Distant metastasis 4- Infections; PID tubo ovarian abscess, Tx; Laparoscopy,
- No screening; inc. CA 12585% Tx; Surgery + chemo Salphingits, endometritis, Laparatomy
risk - Uni/bilateral oophorectamy 5- uterine; Perforation, endometritis,
- Pelvic US show size & Structure - Omentectomy, LN dissection. dysmenorrhae, fibroids.
- Abdominopelvic CT, CXR. - Recurrent Ov. Ca rarely cured palliative Chemo
6- Adnexa; Torsion, ovary cyst rupture etc.
40. Pelvic inflammatory disease
- PID; Spectrum of inflammatory diseases of upper genital tract of women, involves:
42. Sexually transmitted diseases.
endometriosis, salpingitis, oopharitis, myometritis, peritonitis. Mostly asymptomatic so spread more easily. Can cause abortions, congenital diseases of fetus,
infertility etc
1- Acute;ascending infections Sx; Complications;
Sx; vaginal/penile discharge, ulcer and pelvic pain.
from cervix endometrium Acute; may be episodes; Pelvic Tuboovarian abscess,
tubes ovaries pelvic pain, lower abdo tenderness, Hydrosalphinx, HPV; lead to genital warts or N.gonorrhea; bacterium Chlamydia trochomatis;
peritoneum. Fever, discharge. Infertility, Fitz Hugh cervical Ca and other HPV ives on moist mucous Sx; women abnormal vaginal
2- Chronic; Chronic pelvic pain Chronic; May have no Sx. Curtis Syndrome. related cancers. Mostly membranes in urethra, discharge, burning during
following acute PID, but also Progressive organ damage + Tx; Empiric tx; asymptomatic, vagina, rectum, mouth, urination, and bleeding in
may be caused by rare pelvic change. Individualised aut pt, two vaccines available for throat, and eyes. between periods,mostly
infections → TB, Actinomycosis. Dx; Symptoms; Oral Ceftriaxone, women Sx appear 2-5 days but in asymptomatic. Men; pain
3- Silent; Asymptomatic, Mild Minor criteria; lower abdo Doxycyclin, (Cervarix and Gardasil) that men up to a month. when urinating, and abnormal
symptoms tenderness, Metronidazol protect against the types of Men; burning and pain discharge from their penis. If
RF; Early intercourse, multiple - uterine, adnexal tendernes, IV Doxycyclin, HPV that cause cervical while urinating, frequency, not treated in both men and
partners, IUDs, etc. - cervical motion tenderness cefotetan. cancer. HPV can be passed discharge from the penis women, Chlamydia can infect
- Affect 1:4 women, mostly <25 Additional criteria; Oral t Surpery_ Total abdo through genital-to-genital (white, green, or yellow in the urinary tract and
Yo >38.3°C, abnormal discharge, inc. Hysterectomy, Bilateral contact as well as during oral color), red or swollen potentially lead to PID. PID,
- Chronic damage, infertility, ESR & CRP + gonorrhoe, salpingooopherectomy. sex. It is important to urethra, swollen or tender infertility. It can cause a
may cause ectopic pregnancy, chlamydia, Tuboovarian abscess, remember that the infected testicles, or sore throat. woman to have a potentially
chronic menstrual problems endometriosis, laparascopic partner might not have any Women; vaginal discharge, deadly ectopic pregnancy,
Etio; STDS Chlamydia evidence. symptoms. burning or itching while Tx; antibiotics
trichomatis /Neisseria Techniques; Cervical gram stain, urinating, painful sexual
gonorrhea. Serum hCG, US, CT, loparoscopy. intercourse, severe pain in
- Reproductive tract damage - Blood; leukocytosis, inc. ESR. lower abdomen or fever
(pregnancy, surgery), however many women do
- Endogenous infections not show any symptoms
(anaerobes, E. coli etc). Tx; antibiotics
 HSV; Syphilis by bacterium HIV; virus kills CD4 cells.
HSV-1; acquired orally and T.pallidum. Untreated, it Carried in body fluids, and is Urogynecology; 3. Overflow incontinence occurs because of
causes cold sores, can lead to complications spread by sexual activity. It Urinary incontinence - types underactivity of the detrusor muscle. This
HSV-2 is usually acquired during and death. can also be spread by 1. Stress urinary incontinence (SUI) is the form of incontinence is associated with
sexual contact and affects the Sx; ulceration of the uro- contact with infected blood, loss of urine that occurs with increased retention of urine. The bladder does not
genitals but genital tract, mouth or breast feeding, childbirth, abdominal pressure, such as coughing or empty completely, and "dribbling" of urine
Some are asymptomatic or have rectum; if left untreated and from mother to child straining. SUI is the result of loss of anatomic occurs.
very mild symptoms. Sx; small the symptoms worsen. during pregnancy. support of the urethrovesical junction or 4. Extraurethral sources of urine include
fluid-filled blisters, headaches, Trichomoniasis; In most advanced stage, an urethra. It most commonly occurs following genitourinary fistulas, which result from
backaches, itching or tingling individual is said to pelvic floor muscle and nerve damage that obstetric injuries or follow pelvic surgery or
sensations in the genital or anal have AIDS resulted from pregnancy and childbirth. radiation. These typically cause continuous
area, pain during urination, Flu Sx; In the primary stage, flu Urethral hypermobility or Intrinsic sphincter leaking of urine.
like symptoms, swollen glands, or like symptoms (headache, deficiency Urinary incontinence- Treatment
fever. Herpes is spread through fatigue, fever, muscle aches) 2. Urge incontinence is defined by the  Pelvic muscle rehabilitation may be
skin contact with a person for about 2 weeks. In the symptom of urine loss that occurs when the helpful for
infected with the virus. The virus asymptomatic stage, patient experiences urgency, or a strong  both SUI and DO
affects the areas where it symptoms usually desire to void. This type of incontinence is  Kegel exercises;
entered the body. This can occur disappear, and the patient often accompanied by symptoms of urinary  Vaginal cones;
through kissing, vaginal can remain asymptomatic frequency, urgency, and nocturia. Urge  Electrical stimulation;
intercourse, oral sex or anal sex. for years. When HIV incontinence includes the following subtypes:  Pessaries;
The virus is most infectious progresses to the Detrusor overactivity and Neurogenic DO  Drug therapy;
during times when there are symptomatic stage, the  Surgery.
visible symptoms, however those immune system is 44. Infertility.
who are asymptomatic can still weakened, and has a low
Def: No conception after 1 year of Assisted Repro Tech. (ART);
spread the virus through skin cell count of CD4+ T Cells.
contact. When the HIV infection unprotected intercourse. 1- IVF Stimulate ovaries to produce
TR; no cure for the disease. becomes life-threatening, it Fecundability = Monthly probability of multiple follicles GnRH gponist +
antiviral medications that treat is called AIDS. opportunistic pregnancy (20% in fertile couple) ontagonist to supress LH ovulation
its symptoms and lower the risk infections and die as a result Types; 1°  (never establish pregnancy) triggered by hCG 36h loter oocytes
of transmission (Valtrex). 2° (previous conceived) retrieved, incubated w/sperm, embryos
43. Pelvic organ prolapse and urogynecology. Etio; ovulatory dysfunction (25%) transfered.
Prolapse Protrusion of uterus -/+ Sx; Heaviness, discomfort in pelvis - Ovarian aging 2- ICSI (intracytoplasmic sperm
vagina beyond normal anatomical - Feeling of lump coming down - Tubal factor (35%) injection) Sperm injected directly to
confines. - Discomfort, backache - Endometriosis (35%) cyplasm of oocyte (mostly in male factor
Cystourethrocele Retection, Frequency,
Classes; - Male factor (40%) infertility)
urgency
1- Cystocele; Prolopse of of ant. Vaginal - Uterine, vaginal tract abnormality (3%) 3- GIFT (Gamete intrafallopion
Rectocele Constipain, Difficult defecation.
wall, involve bladder. Dx; - Unexplained (10%) Transfer) Oocytes retrived from
2- Enterocele; prolapse of upper post. Tx;Conservative Physiotherapy, Tx; Evaluation of coital technique, ovaries. oocyte + spermatozoa placed
wall of vagina. Intravaginal devices change every 6m; Ring frequency into fallopion tube fertilized.
3- Rectocele; Prolopse of lower post. pessary, Shelf pessary, Hodge pessary, Cube + - History of PID, STD, pelvic surgery etc, 4- zygote Intrafollopian Transfer
wall of vagina involve ant. rectum wall. doughnest pessary. - Smoking cessation, decr. alcohol Zygote placed to follopian tube.
4- uterine prolapse; Prolapse of uterus, Surgery Anterior colporrhaphy, Paravaginal - Folic acid supplementation
cervix, upper vagina. repair, Vaginal hysterectomy, - Genetic concelling İnc. maternal or
GRADES Baden-Walker Classification Sacrocolpoprexy.
paternal age, genetics
1st degree Lowest part of prolapse descent
to halfway down vaginal axis.
2nd degree descent to level of introitus.
3rd degree lie outside vagina.
45. Contraception. DISORDERS IN PEDIATRIC – ADOLESCENTS
Contraception (birth control) refers to methods of preventing conception. 1. Vulvovaginitis; S. 2. Labial fusion; 3. Vaginal atresia; 4. Lichen
Methods; aureus, Candida, - Partia /Complete (Mullerian sclerosis et
1- Barrier methods; 4- Combination Oral Trichomonas, adhesion of labia agenesis) atropicus;
- Condoms; Female & Male Contraceptives; Contact, Atrophic, minora. - Agenesis of - Chonic inflam.
- Spermicides; Cream, Jell etc. MoA; inhibit LH surge foreign body. Etio; absence of mullerian duct & disease
- vaginal sponges - Supress oviculation Sx; discharge, estrogen cause atresia of upper w/white
- Diaphragms - Thicken cervical mucus prunitus, pain, infections 1/3 vagina atropic
frequency, urgency. inflam adhesion Sx; Asymptomatic plaques,
- Cervical cups - Alter tube motility
Dx: Gram, culture, or trauma, before puberty. pruritus, pain,
2- Intrauterne devices; - Alter endometrium implantation
DNA (PCR), US congenital defect. Amenorrhae, genital scaring.
a- Copper Impreprated IUD 10year impair.
TX: Removing foreign Sx; Asymtomatic, infertility Dx; Punch
b- Progestin Impregnated IUD 5 year - Contain; estrogen, progestin body, UTI, vaginitis Dx; Normal FSH, biopsy
3- Progestin Only Methods; Risks: Thromboembolism, HT, liver anibiotics/antifungals. Dx; Clinical exan LH, estradiol, Tx; steroids,
- Mod of action; Thicken mucus → tumor, inc. breast Ca risk. Tx; Topical estrogen testosterone, US surgery
prevent sperm decr. ciliary action of Emergency Contraception; Tx; Vaginoplasty
fallopion tube. * Morning after pill; in 120h after 5. Precocious Puberty; 6. Delayed 7. Primary
- Minipill intercourse - 2° sexual characteristics appear <8yo in Puberty; amorrhaea;
- injectable Progestin * Copper IUD girls. - Due to; Chronic After 15yo.
- Implanted Progestin Types; anovulation, - Also
Central Inc. GnRH, inc. estrogen, decr.LH *Constitutional examination
46. Pediatric and aldolescent gynecology. & FSH, brain tumor, hydrocephalus. delay, anatomic needed in
Puberty; sequence of physical Phases of puberty; activation of Peripheral Inc. Estrogen, inc. LH & FSH, abnormality, adolescents,
&physiological changes during adolescent adrenal androgens; Ovarian/adrenal tumors, CAH. hypergonadic Trauma,
years that cause full physical & sexual adrenarche (8yo)→ gonadarche (9- İsosexual hypogonadism, dysfunctional
development. 10yo) thelarche (8-11yo) Heterosexual hypogonadic uterine
Characters = Age; 8-13yo growth spurt (11,5-16,5yo) Dx; Physical/radilogical signs hypogonadism. bleeding.
First sign breast enlargement + pubarche (12yo) menarche (10- - Endocrine profile Gonadotropin levels, Dx; History;
menarche after 2 years. 16yo). Thyroid function tests. delayed growth,
- Imaging Rule out other causes (Tumors family history .
- pubic hair, acne, axillay hair Tanner Puberty Stages
etc) - X-ray of hand
- Growth spurt 5 stage;
Tx; GnRH agonist supress pituitary. LH, FSH, TSH.
Endocrine glands that control puberty;
Surgery/chemo Tx; estrogen
Pineal, hypothalamus (GnRH), pituatory
(LH, FSH), gonads (estrogen,
testosterone), Suprarenal (androgens).
47. Diagnostic methods in gynecology - Ultrasound, disorders, endometrial cancer. - Metformin, IVF
hysteroscopy and laparoscopy.
Ultrasound 49. Menopouse. Hormone replacement therapy
TA US; easiest method of Transvaginal US Menopause Age 47-54 Hormone replacement therapy
assessing the uterus, • Ovaries: Performed to diagnose ovarian cysts, Def. Cessation of menstruation & depletion Hormone therapy (HT) refers to the
ovaries, and adnexal tumors, and follicular maturation Uterus of oocytes. Absence of menses after combined use of estrogen and
structures. • Myometrium (e.g., to diagnose leiomyomas) the final menstrual period (FMP); followed progestogen in sub-contraceptive
Assessment of: • Endometrium: by amenorrhea for 1 year doses;
• Urogenital tract - Echogenic layer in the long axis view of the uterus Can be spontaneous or due to surgery, Aim; reduce symptoms resulting from
• Assessment of fetal (referred to as the "endometrial stripe") chemo,radiation etc estrogen depletion such as hot
development - Endometrial thickness varies with the menstrual cycle Climactetric period; transition from optimal flushes, sleeplessness, and mood
• Pelvic organs - Postmenopausal women with an endometrial menstruations to menopause. Ovulation disorders;
Breast US thickness greater than 8 mm should undergo a follow- less frequent 1-2 times/year, occur every 3- Treat vaginal dryness and atrophy
to assess breast lesions up ultrasound after 1-3 months 4 month Minimize the risk of disorders that
which were detected by - Postmenopausal women with an endometrial Sx; Hot flushes, vaginal atropy, may be more frequent during
palpation, thickness greater than 10 mm should undergo osteoporosis, inc. CV disease risk, Sweating, hormone therapy
mammography, and/or hysteroscopy and endometrial curettage to rule out vaginal dryness, mood changes. *Risks and contraindications
breast MRI endometrial carcinoma. Tx; Hormone replacement theropy (ART)  • Undiagnosed abnormal genital
also to assess axilla for • Assessment of fetal development (1st trimester) Help preventing osteoporosis, may cause bleeding
lymph node involvement if • Measurement of cervical length in cases of cervical inc. CV disease or thromboembolic disease. • Known or suspected breast
there is suspicion for incompetence - Estrogen wage women w/o uterus cancer or estrogen-dependent
breast cancer. - Estrogen + progestin women w/ uterus neoplasia
Also SERMS (Selective estrogen receptor • Active or history of thrombosis
Hysteroscopy Laparoscopy modulators (tamoxifen, raloxifene) • History of stroke or myocardial
• A fiberoptic scope is In gynecology, diagnostic laparoscopy may be used to breast, endometrium Ca risk. infarction in the previous year
introduced trans-cervically inspect the outside of the uterus, ovaries and fallopian Dx; Greene climacteric scale • Active liver dysfunction or
into the uterus to tubes, for example in the diagnosis of female infertility. - Menopause ratry scale disease
diagnose and/or treat Usually, there is one incision near the navel and a Etio; Age, premature ovarion failure, • Known or suspected pregnancy
uterine pathologies. second near to the pubic hairline. surgeries (oophorectomy) • Known hypersensitivity
• Indications; For gynecological diagnosis, a special type of chemo/radiotherapy Estrogen therapy (ET) refers to the
Endometrial polyp laparoscope can be used, called a fertiloscope. A *Terms; use of estrogen without a
Abnormal uterine bleeding fertiloscope is modified to make it suitable for trans- - Premenapause→ Up to last period progestogen, usually only given in
Uterine curettage vaginal application. - Perimenapause around menapause women who have undergone
Myomectomy for uterine It is used for many gynecologic procedures, such as - Postmenapause after finishing of hysterectomy
polyps removal of an ectopic pregnancy, treatment of menses
endometriosis, ovarian cystectomy and hysterectomy. POSTMENOPAUSE Clinical Sx;Endometrium, myometrium atropy, skin collagen
48. Polycystic ovarian syndrome - diagnosis and treatment. decrease, skin hairs increase,CNS effects, cognitive function decrease, CV disease risk
- PCOS; Clinical syndrome caused by androgen excess characterised by mild obesity, increase, hot flashes, osteoporosis
amenorrhae or Irregular menses. Cysts may formed in ovaries
RF; Obesity, not enough exercise, genetics Dx; High androgens
Sx; heavy mens periods, irregular menses - Ovarian cysts (US)
- excess hair, acne, pelvic pain - LH /FSH ratio inc.
- Infertility Complications; Type II DM, obesity, Tx; Diet, progesterone, oral
obstructive sleep apnea, heart diseases, mood contraceptives