Firstaid Step 3 Obgyn

Front 1

What should all prenatal visits document?

Back 1

All prenatal visits should document
1) weight
2) BP
3) extremity edema
4) urine protein
5) glucose
6) fundal height (> 20 weeks)
7) fetal heart rate.

Front 2

What are the prenatal recommendations?

Back 2

1) Weight gain: Average-size women should gain 25–35 lbs; obese women should gain less (15–25 lbs) and thin women more.
2) Nutrition: Requirements for total calories, protein, iron, folate, calcium, and zinc should ↑. All patients should take prenatal vitamins.
-Caloric intake: An additional 300 kcal/day is needed during pregnancy and 500 kcal/day during breast-feeding.
-Folate: Supplement with 400 μg/day to ↓ the risk of neural tube defects (NTDs). Women with twin gestation or a prior history of a fetus with NTDs should receive 4 mg/day.
-Iron: Supplement in the latter half of pregnancy to prevent anemia.
-Calcium: Supplement in the later months of pregnancy and during breast-feeding.
3) Smoking and alcohol cessation.
4) Prenatal labs: See Table 14-1 for lab work that should be scheduled during pregnancy.

Front 3

Which labs should take place during the initial prenatal visit?

Back 3

1) CBC
2) blood type
3) Rh antibody screen
4) UA with culture
5) Pap smear
6) cervical gonorrhea and chlamydia cultures
7) rubella antibody titer, hepatitis B surface antigen, syphilis screen, PPD, HIV.
Toxoplasmosis and sickle cell screening for at-risk patients.
Women with prior gestational diabetes or a family history (in a first-degree relative) should get early glucose testing.

Front 4

Which labs should take place during 6-11 weeks?

Back 4

Ultrasound to determine GA (more accurate than later scans).

Front 5

Which labs should take place during 15-19 weeks?

Back 5

1) Triple-marker screen/quadruple test (quad screen). 2) Offer amniocentesis for those of advanced maternal age (≥ 35 years of age at delivery).

Front 6

Which labs should take place during 18-21 weeks?

Back 6

Screening ultrasound to survey fetal anatomy, placental location, and amniotic fluid.

Front 7

Which labs should take place during 26-28 weeks?

Back 7

1) One-hour glucose challenge test.
If ≥ 140 mg/dL, follow with a three-hour glucose tolerance test.
2) Repeat hemoglobin/hematocrit.

Front 8

Which labs should take place during week 28?

Back 8

1) RhoGAM injection for Rh- patients.
2) Start fetal kick counting (the patient should count 10 fetal movements in < 1 hour).

Front 9

Which labs should take place during 35-37 weeks?

Back 9

1) Screen for group B streptococcus (GBS) with a rectovaginal swab.
2) Repeat hemoglobin/hematocrit.
3) Cervical gonorrhea and chlamydia cultures, RPR, and HIV (in at-risk patients).
4) Assess fetal position with Leopold maneuvers and ultrasound.

Front 10

TRIPLE-MARKER SCREEN/QUADRUPLE TEST (QUAD SCREEN)

Back 10

1) Measured between 15 and 20 weeks’ gestation.
2) Any maternal serum α-fetoprotein (MSAFP) result > 2.5 multiples of the mean (MoM) can signify an open NTD, an abdominal wall defect, multiple
gestation, incorrect dating, fetal death, or placental abnormalities.
3) The sensitivity for detecting chromosomal abnormalities (trisomies 18 and 21) can be ↑ through the addition of estriol and β-hCG (triple-marker
screen) to MSAFP. See Table 14-2 for trends in the detection of genetic abnormalities.
3) The addition of inhibin-A to the three markers above (quadruple test) will ↑ the sensitivity for Down syndrome.

Front 11

A 32-year-old G4P2 woman at 16 weeks’ gestation has an abnormal triple-marker screen that raises concern for trisomy 21. What is the next step?

Back 11

The next step depends on the patient’s desire to confirm the diagnosis. If the patient desires termination of pregnancy with a positive result, amniocentesis would be confirmatory.

Front 12

When is AMNIOCENTESIS performed?

Back 12

Performed primarily between 15 and 20 weeks’ gestation to detect possible genetic diseases or congenital malformations.

Front 13

What is amniocentesis used for?

Back 13

■ Amniocentesis is used:
■ In conjunction with an abnormal triple-marker screen/quadruple test.
■ In women > 35 years of age at the time of delivery.
■ In Rh-sensitized pregnancy to ascertain fetal blood type or to detect
fetal hemolysis.
■ For the evaluation of fetal lung maturity in the third trimester.

Front 14

What are the risks for amniocentesis?

Back 14

■ Risks include fetal-maternal hemorrhage (1–2%) and fetal loss (0.5%).

Front 15

Why is CHORIONIC VILLUS SAMPLING done?

When is it usually done?

Back 15

1) Performed to evaluate possible genetic diseases at an earlier time than is possible with amniocentesis, with comparable diagnostic accuracy.

2) Done at 10–12 weeks’ gestation via transabdominal or transvaginal aspiration of chorionic villus tissue (a precursor of the placenta).

Front 16

Risks for chorionic villus sampling

Back 16

Risks include fetal loss (1–5%) and an association with distal limb defects.

Front 17

NONSTRESS TEST (NST)

Back 17

1) Fetal heart rate is monitored externally by Doppler.
2) A normal response is an acceleration of ≥ 15 bpm above baseline lasting > 15 seconds.
3) A normal or “reactive” test includes two such accelerations in a 20-minute period.
4) An abnormal or “nonreactive” NST warrants a biophysical profile or a contraction stress test
5) A nonreactive NST can be due to fetal sleep cycle, GA < 30 weeks, a fetal CNS anomaly, or maternal sedative or narcotic use.

Front 18

CONTRACTION STRESS TEST (CST)

Back 18

1) Used to assess uteroplacental dysfunction.
2) Fetal heart rate is monitored during spontaneous or induced (nipple stimulation or pitocin) contractions.
3) A normal or “negative” CST has no late decelerations and is highly predictive of fetal well-being.
4) An abnormal or “positive” CST is defined by late decelerations in conjunction with at least 50% of contractions. A minimum of three contractions
within a 10-minute period must be present for an adequate CST.

Front 19

BIOPHYSICAL PROFILE (BPP)

Back 19

1) Ultrasound is used to assess five parameters (see the mnemonic)
2) A score of 2 (normal) or 0 (abnormal) is given to each of the parameters.
3) A normal or “negative” test (a score of 8–10) is reassuring for fetal wellbeing.
■ An abnormal or “positive” test (a score < 6) is worrisome for fetal compromise.

Front 20

Mnemonic for BIOPHYSICAL PROFILE (BPP)

Back 20

When performing a BPP, remember
to—
Test the Baby, MAN!
Fetal Tone
Fetal Breathing
Fetal Movements
Amniotic fluid volume
Nonstress test

Front 21

An HbA1c > 6.5 prior to conception or during the first trimester will lead to a higher rate of fetal malformations.

Back 21

An HbA1c > 6.5 prior to conception or during the first trimester will lead to a higher rate of fetal malformations.

Front 22

What is the most common medical complication of pregnancy?

Back 22

Diabetes Mellitus

Front 23

A 32-year-old G1P0 at 34 weeks’ gestation with a diagnosis of preeclampsia presents with a refractory headache and nausea. She is found to have a BP of 208/112 and 3+ protein on urine dipstick. Her labs are pending. What is the next step?

Back 23

The patient is presenting with severe preeclampsia that raises concern for the development of eclampsia. You should administer antihypertensives and magnesium for seizure prophylaxis and prepare for emergent delivery.

Front 24

What is Pre-eclampsia?

Eclampsia?

Back 24

Preeclampsia is characterized by hypertension and proteinuria and is thought to be due to ↓ organ perfusion 2° to vasospasm and endothelial activation.
Risk factors include nulliparity, African American ethnicity, extremes of age, multiple gestations (ie, twins), renal disease, and chronic hypertension.
Eclampsia is defined as seizures in a patient with preeclampsia.
Preeclampsia is further distinguished as follows:
■ Mild: Systolic BP (SBP) > 140, diastolic BP (DBP) > 90, and 1+ on dipstick or > 300 mg on 24-hour urine.
■ Severe: SBP > 160, DBP > 110, and 3+ on dipstick or > 5 g on 24-hour urine.

Front 25

How is Preeclampsia and Eclampsia diagnosed?

Back 25

■ Check UA, 24-hour urine for protein and creatinine clearance, CBC, BUN, creatinine, uric acid, LFTs, PT/PTT, fibrinogen, and a toxicology screen.
■ Determine the precise GA; consider amniocentesis to assess fetal lung maturity for mild preeclampsia.
■ Diagnosis is based on clinical findings as described in Table 14-5.

Front 26

What is HELLP syndrome?

Back 26

Hemolysis
Elevated Liver enzymes
Low Platelets

Front 27

How do you treat pre-eclampsia and eclampsia?

Back 27

Definitive treatment is delivery. See Table 14-5 for management

Front 28

HYPEREMESIS GRAVIDARUM

Back 28

■ Defined as refractory vomiting that leads to weight loss, poor weight gain, dehydration, ketosis from starvation, and metabolic alkalosis. Typically
persists beyond 14–16 weeks’ gestation.

Front 29

HYPEREMESIS GRAVIDARUM differential Dx

Back 29

DDx: Rule out molar pregnancy, hepatitis, gallbladder disease, reflux, and gastroenteritis.

Front 30

HYPEREMESIS GRAVIDARUM risk factors

Back 30

Risk factors include nulliparity, multiple pregnancies, and trophoblastic disease.

Front 31

HYPEREMESIS GRAVIDARUM dx

Back 31

Dx: Labs show hyponatremia and a hypokalemic, hypochloremic metabolic alkalosis. Ketonuria on UA suggests starvation ketosis.

Front 32

HYPEREMESIS GRAVIDARUM Tx

Back 32

Tx: If there is evidence of weight loss, dehydration, or altered electrolytes, hospitalize and give antiemetics, IV hydration, and vitamin and electrolyte replacement. Advance the diet slowly and avoid fatty foods.

Front 33

Types of GESTATIONAL TROPHOBLASTIC DISEASE

Back 33

Can range from benign (eg, hydatidiform mole) to malignant (eg, choriocarcinoma).
Hydatidiform mole accounts for approximately 80% of cases.

Front 34

GESTATIONAL TROPHOBLASTIC DISEASE Symptoms

Back 34

SYMPTOMS/EXAM
■ Suspect in patients with fi rst-trimester uterine bleeding and excessive nausea and vomiting.
■ Look for patients with preeclampsia or eclampsia at < 24 weeks.
■ Other findings include uterine size greater than dates and hyperthyroidism.
■ No fetal heartbeat is detected.
■ Pelvic exam may show enlarged ovaries and possible expulsion of grapelike
molar clusters into the vagina or blood in the cervical os

Front 35

GESTATIONAL TROPHOBLASTIC DISEASE Dx

Back 35

■ β-hCG levels are markedly ↑ (usually > 100,000 mIU/dL).
■ Pelvic ultrasound shows a “snowstorm” appearance with no gestational sac and no fetus or heart tones present.
■ Obtain a CXR to look for metastases.

Front 36

GESTATIONAL TROPHOBLASTIC DISEASE Treatment

Back 36

TREATMENT
■ D&C.
■ Carefully monitor β-hCG levels after D&C for possible progression to malignant disease.
■ Pregnancy prevention (contraception) is needed for one year to ensure accurate monitoring of β-hCG levels.
■ Treat malignant disease with chemotherapy and residual uterine disease with hysterectomy.

Front 37

What is POSTPARTUM HEMORRHAGE and its complications?

Back 37

Defined as blood loss of > 500 mL during a vaginal delivery or > 1000 mL during a cesarean section occurring before, during, or after delivery of the
placenta. Table 14-6 summarizes common causes.
■ Complications include Sheehan’s syndrome (see below).

Front 38

SHEEHAN’S SYNDROME (POSTPARTUM HYPOPITUITARISM)

Back 38

■ The most common cause of anterior pituitary insufficiency in adult females. It occurs 2° to pituitary ischemia, usually as a result of postpartum blood loss and hypotension.

Front 39

SHEEHAN’S SYNDROME (POSTPARTUM HYPOPITUITARISM)

Back 39

Sx/Exam:
■ The most common presenting symptom is failure to lactate as a result of ↓ prolactin levels.
■ Other symptoms include lethargy, anorexia, weight loss, amenorrhea, and loss of sexual hair, but these may not be recognized for many years.

Front 40

SHEEHAN’S SYNDROME (POSTPARTUM HYPOPITUITARISM) Treatment

Back 40

Tx: Lifelong hormone replacement therapy (corticosteroids, levothyroxine, estrogen and progesterone).

Front 41

A 31-year-old healthy woman develops fevers (39.1°C/102.4°F) and shaking chills eight hours following a C-section performed for fetal malposition. The baby is doing well, and the amniotic fluid at C-section is clear.
What is the likely source of infection?

Back 41

The uterus (endometritis). This is a rapid postoperative presentation, making the standard causes of postoperative fever less likely.

Front 42

INTRAPARTUM AND POSTPARTUM FEVERS

Back 42

Most commonly due to infections (see Table 14-7).
■ Remember the mnemonic for the 7 W’s for the causes of postpartum
fever.

Front 43

The 7 W’s of postpartum fever:

Back 43

Womb—endomyometritis
Wind—atelectasis, pneumonia
Water—UTI
Walk—DVT, pulmonary embolism
Wound—incision, lacerations
Weaning—breast engorgement, mastitis,
breast abscess
Wonder drugs—drug fever

Front 44

Whats is MASTITIS?

Back 44

Cellulitis of the periglandular tissue in breast-feeding mothers, typically due to S aureus, occurring at about 2–4 weeks postpartum.

Front 45

MASTITIS Symptoms

Back 45

Sx/Exam: Symptoms include breast pain and redness along with a high fever, chills, and flulike symptoms. Look for focal breast erythema, swelling, and tenderness. Fluctuance points to a breast abscess.

Front 46

MASTITIS differential Dx

Back 46

DDx: Distinguish from simple breast engorgement, which can present as a swollen, firm, tender breast with low-grade fever and a breast abscess.

Front 47

MASTITIS Dx

Back 47

■ Dx: Diagnosis includes breast milk cultures and CBC.

Front 48

MASTITIS Tx

Back 48

Tx: Treat with dicloxacillin or erythromycin. Continue nursing or manually expressing milk to prevent milk stasis. Incision and drainage is necessary if an abscess is present.

Front 49

Contraindications to breast-feeding?

Back 49

Contraindications to breast-feeding include HIV infection, active hepatitis, and certain drugs (eg, tetracycline, chloramphenicol, warfarin).

Front 50

During which trimesters should CT scans be avoided

Back 50

CT scans of the fetus should be avoided at all trimesters of pregnancy in light of concerns over increasing the risk of childhood cancer.

Front 51

Teratogens in Pregnancy

Back 51

Radiation: Diagnostic and nuclear medicine studies have not been shown to pose any risk of fetal teratogenicity if overall exposure during pregnancy
is < 5000 mrads. Table 14-8 outlines radiation exposure levels associated with such procedures.
■ Medications: See Table 14-9 for safe and teratogenic medications during pregnancy.

Front 52

What does oligohydramnios almost always indicates?

Back 52

Oligohydramnios almost always indicates the presence of a fetal abnormality.

Front 53

What is INTRAUTERINE GROWTH RESTRICTION (IUGR)?

Back 53

■ Defined as an estimated fetal weight at or below the 10th percentile for GA. See Table 14-10 for common causes of IUGR.

Front 54

INTRAUTERINE GROWTH RESTRICTION (IUGR) symptoms

Back 54

Sx/Exam: Suspect IUGR clinically if the difference between fundal height and GA is > 2 cm.

Front 55

INTRAUTERINE GROWTH RESTRICTION (IUGR) treatment

Back 55

Tx: Focus on prevention—eg, smoking cessation, BP control, and dietary changes. Order an ultrasound every 3–4 weeks to assess interval growth.
Deliver once the pregnancy reaches term.

Front 56

RHESUS (Rh) ISOIMMUNIZATION

Back 56

When fetal Rh-⊕ RBCs leak into Rh- maternal circulation, maternal anti-Rh IgG antibodies can form. These antibodies can cross the placenta and react with fetal Rh-⊕ RBCs, leading to fetal hemolysis (erythroblastosis fetalis).

Front 57

RHESUS (Rh) ISOIMMUNIZATION Treatment

Back 57

TREATMENT
■ Give RhoGAM to Rh- women:
■ With prior delivery of an Rh-⊕ baby.
■ If the father is Rh ⊕, Rh status is unknown, or paternity is uncertain.
■ If the baby is Rh ⊕ at delivery.
■ If the woman has had ectopic pregnancies, abortions, amniocentesis or other traumatic procedures during pregnancy, vaginal bleeding, blood transfusions, or placental abruption.
■ Sensitized Rh- women with titers > 1:16 should be closely monitored for evidence of fetal hemolysis with serial ultrasound and amniocentesis or
middle cerebral artery Doppler velocimetry.
■ In severe cases, intrauterine blood transfusion via the umbilical vein or preterm delivery is indicated.

Front 58

A 32-year-old G3P2 at 35 weeks’ gestation is brought to the ER by ambulance with severe abdominal pain following a motor vehicle accident. Her BP is 92/47 and her pulse is 135/min. Her exam is significant for a severely tender, asymmetric gravid uterus. Fetal monitoring is worrisome. What is the cause?

Back 58

Uterine rupture. The patient needs to go to the OR emergently for an exploratory laparotomy and a C-section.

Front 59

Define THIRD-TRIMESTER BLEEDING

Back 59

■ Describes any bleeding after 20 weeks’ gestation.

Front 60

Most common causes of THIRD-TRIMESTER BLEEDING

Back 60

The most common causes are placental abruption and placenta previa (see Table 14-12).
■ Other causes of bleeding include bloody show, preterm/early labor, vasa previa, genital tract lesions, and trauma (eg, intercourse).

Front 61

A 26-year-old woman at 30 weeks’ gestation presents with PPROM without evidence of infection. What medication should be administered?

Back 61

Steroids for fetal lung maturation and prophylactic antibiotics for chorioamnionitis.

Front 62

Define PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM)

Back 62

Defined as spontaneous ROM at < 37 weeks, prior to the onset of labor. Distinguished from premature rupture of membranes (PROM), which refers to loss of fluid at term prior to the onset of contractions. Risk factors include low socioeconomic status, young maternal age, smoking, and STDs.

Front 63

PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM) Symptoms

Back 63

SYMPTOMS/EXAM
■ Sterile speculum exam shows pooling of amniotic fluid in the posterior vaginal vault.
■ Look for cervical dilation.

Front 64

PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM) Dx

Back 64

DIAGNOSIS
■ Nitrazine paper test: Paper turns blue in alkaline amniotic fluid.
■ Fern test: A ferning pattern is seen under the microscope after amniotic fluid dries on glass slide.
■ Determine AFI by ultrasound to assess amniotic fluid volume.

Front 65

PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM) Treatment

Back 65

TREATMENT
■ Obtain cultures and/or wet mounts to look for infectious causes. If signs of infection are present, assume amnionitis (maternal fever, fetal tachycardia,
foul-smelling amniotic fluid). Give antibiotics (ampicillin +/–gentamicin) and induce labor regardless of GA.
■ If no signs of infection are present and GA is 24–32 weeks, treat with antibiotics (ampicillin and erythromycin) to prolong pregnancy and steroids
for fetal lung maturation +/– tocolytics.
■ If no signs of infection are present and GA is ≥ 33 weeks, hospitalize and treat expectantly until labor begins, signs of infection are seen, or 34 weeks’
gestation is achieved.

Front 66

Define PRETERM LABOR

Back 66

Labor between 20 and 36 weeks’ gestation.

Front 67

PRETERM LABOR Symptoms

Back 67

SYMPTOMS/EXAM
■ Patients may complain of menstrual-like cramps, uterine contractions, low back pain, pelvic pressure, new vaginal discharge, or bleeding.
■ Rule out cervical insufficiency (treated with cerclage if early enough) and preterm contractions (no cervical dilation).
■ Can lead to fetal respiratory distress syndrome, intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis, or fetal death.

Front 68

PRETERM LABOR Dx

Back 68

DIAGNOSIS
■ Obtain an ultrasound to verify GA, fetal presentation, and AFI.
■ Look for regular uterine contractions (three or more contractions lasting 30 seconds each over a 30-minute period) coupled with a concurrent cervical
change at < 37 weeks’ gestation.

Front 69

PRETERM LABOR Treatment

Back 69

TREATMENT
■ Begin with hydration and bed rest.
■ Unless contraindicated, administer steroids (to accelerate fetal lung maturity) +/– tocolytics.
■ Give penicillin or ampicillin for GBS prophylaxis if preterm delivery is likely.

Front 70

Define FETAL MALPRESENTATION

Back 70

Defined as any presentation other than cephalic (head down).
Breech presentation is the most common fetal malpresentation (affects 3% of all pregnancies).

Front 71

FETAL MALPRESENTATION Dx

Back 71

DIAGNOSIS
■ Perform Leopold maneuvers to identify fetal lie.
■ Check by ultrasound if there is any doubt.

Front 72

FETAL MALPRESENTATION treatment

Back 72

TREATMENT
■ Follow: Up to 75% of cases spontaneously change to cephalic presentation by 38 weeks.
■ External cephalic version can be attempted at 36–37 weeks’ gestation in the setting of persistent malpresentation.
■ Involves pressure applied to the maternal abdomen to turn the infant.
■ Risks of the procedure are placental abruption and cord compression; the infant must be monitored after the procedure, and consent must be obtained for emergent C-section.

Front 73

Define SHOULDER DYSTOCIA

Back 73

Defined as difficult delivery due to entrapment of the fetal shoulder at the level of the pubic bone. Risk factors include the following:
■ A prior history of a shoulder dystocia.
■ Fetal macrosomia or inadequate pelvis.

Front 74

SHOULDER DYSTOCIA Dx

Back 74

DIAGNOSIS
■ A prolonged second stage of labor with retraction of the head (“turtle sign”) back into the vaginal canal after pushing.
■ After delivery of the head, difficulty delivering the anterior shoulder without performing additional maneuvers.

Front 75

SHOULDER DYSTOCIA treatment

Back 75

TREATMENT
Flex and open the maternal hips (McRoberts maneuver), followed by suprapubic pressure. Most dystocias will be relieved with these two maneuvers:
■ Delivery of the posterior fetal arm or internal rotation of the fetal shoulders to lessen the shoulder diameter.
■ Replacement of the fetal head into the vaginal canal, followed by cesarean section (Zavanelli maneuver).

Front 76

Define RECURRENT ABORTION

Back 76

Defined as three or more consecutive pregnancy losses before 20 weeks’ gestation.

Front 77

Cause of RECURRENT ABORTION

Back 77

Usually due to chromosomal or uterine abnormalities, but can also result from hormonal abnormalities, infection, or systemic disease.

Front 78

RECURRENT ABORTION Dx

Back 78

Dx: Based on clinical and lab findings.
■ Perform a pelvic exam (to look for anatomic abnormalities).
■ Check cervical cultures for chlamydia and gonorrhea.
■ Perform a maternal and paternal genetic analysis.
■ Obtain a hysterosalpingogram to look for uterine abnormalities.
■ Obtain TFTs, progesterone, lupus anticoagulant, and anticardiolipin antibody.

Front 79

RECURRENT ABORTION treatment

Back 79

■ Tx: Treatment is based on the diagnosis.

Front 80

What should all women with potential spontanous abortions receive

Back 80

All women with potential SABs should receive RhoGAM if appropriate.

Front 81

Define SPONTANEOUS ABORTION (SAB)

Back 81

Defined as nonelective termination of pregnancy at < 20 weeks’ gestation.
Also known as “miscarriage.” Occurs in 10–15% of clinically recognizable pregnancies.

Front 82

SPONTANEOUS ABORTION (SAB) Symptoms

Back 82

SYMPTOMS/EXAM
Differentiate types of SABs on the basis of symptoms, cervical exam, and ultrasound (see Table 14-14).

Front 83

SPONTANEOUS ABORTION (SAB) Differentials

Back 83

DIFFERENTIAL
Common causes of fi rst-trimester bleeding include normal pregnancy (implantation bleeding), postcoital bleeding, ectopic pregnancy, vaginal
or cervical lesions, pedunculated myomas or polyps, and extrusion of molar pregnancy.

Front 84

SPONTANEOUS ABORTION (SAB) treatment

Back 84

TREATMENT
■ Hemodynamic monitoring for significant bleeding.
■ Check β-hCG to confirm pregnancy and transvaginal ultrasound to establish GA and rule out ectopic pregnancies; assess fetal viability or check for
remaining tissue in the setting of a completed abortion.
■ Check blood type and antibody screen; give RhoGAM if appropriate.

Front 85

A 38-year-old woman has a history of bilateral tubal ligations five years ago. She presents to her gynecologist with intermittent and painless noncyclic
vaginal bleeding of two months’ duration. She otherwise feels well and has a normal cervical exam. What is the next step?

Back 85

You must rule out endometrial cancer by performing an endometrial biopsy or
a D&C (the gold standard).

Front 86

Women greater than 35 years old with unexplained bleeding needs what?

Back 86

Any woman > 35 years of age
with unexplained bleeding needs
an endometrial biopsy to rule out
malignancy.

Front 87

Menorrhagia

Back 87

Menorrhagia: Heavy or prolonged menstrual fl ow.

Front 88

Metrorrhagia

Back 88

■ Metrorrhagia: Bleeding between menses.

Front 89

Metromenorrhagia

Back 89

■ Metromenorrhagia: Heavy bleeding at irregular intervals.

Front 90

Causes of uterine bleeding—

Back 90

MS. PDA
Malignancy
Systemic
Postmenopausal
Dysfunctional
Anatomic

Front 91

Abnormal Uterine Bleeding Dx

Back 91

EXAM/DIAGNOSIS
■ Determine if the bleeding is ovulatory or anovulatory.
■ Ovulatory:
■ Characterized by midcycle bleeding or changes in menstrual flow.
■ Can present with premenstrual syndrome symptoms (weight gain, breast tenderness, dysmenorrhea).
■ Anovulatory:
■ Unpredictable bleeding patterns.
■ Excessive and prolonged bleeding due to unopposed estrogen on the endometrium.
■ Seen mostly in adolescent and perimenopausal women.
■ Associated with an ↑ risk of endometrial hyperplasia and cancer.
■ Look for a cervical lesion on speculum exam or an enlarged uterus on bimanual exam.

Front 92

Abnormal Uterine Bleeding treatment

Back 92

TREATMENT
■ Treat the underlying cause.
■ Acute, profuse bleeding can be treated with high-dose IV estrogen, D&C, uterine artery embolization, or hysterectomy.
■ DUB and anovulatory bleeding are treated with OCPs or NSAIDs.

Front 93

Amenorrhea

Back 93

Defi ned as either 1° or 2° amenorrhea.
■ 1° amenorrhea: Absence of menses and lack of 2° sexual characteristics by age 14 or absence of menses by age 16 with or without 2° sexual characteristics.
Associated with gonadal failure, congenital abnormalities, and constitutional symptoms (see Figure 15-1).
■ 2° amenorrhea: Absence of menses for three cycles or for six months with prior normal menses. Etiologies include pregnancy, anorexia nervosa,
stress, strenuous exercise, intrauterine adhesions, chronic anovulation, hypothyroidism, and hyperprolactinemia (see Figure 15-2).

Front 94

Amenorrhea Dx

Back 94

DIAGNOSIS
■ Check β-hCG to make sure the patient is not pregnant.
■ 1° amenorrhea: See Figure 15-1.
■ 2° amenorrhea: See Figure 15-2.

Front 95

Amenorrhea Treatment

Back 95

TREATMENT
Depends on the etiology; may include surgery or hormonal therapy +/– drug therapy.

Front 96

Dysmenorrhea

Back 96

Defined as pain with menstrual periods that requires medication and prevents normal activity. It is divided into 1° and 2° dysmenorrhea.
■ 1° dysmenorrhea: No clinically detectable pelvic pathology. Most likely due to ↑ uterine prostaglandin production.
■ 2° dysmenorrhea: Menstrual pain due to pelvic pathology, most commonly endometriosis, adenomyosis, myomas, or PID.

Front 97

Always rule out pregnancy in a patient
with amenorrhea.

Back 97

Always rule out pregnancy in a patient with amenorrhea.

Front 98

What is Endometriosis

Back 98

Abnormal growth of endometrial tissue in locations other than the uterine lining, usually in the ovaries (called endometriomas or “chocolate cysts”),
cul-de-sac, and broad ligament. Associated with premenstrual pelvic pain due to stimulation from estrogen and progesterone during the menstrual cycle.

Front 99

Endometriosis symptoms

Back 99

SYMPTOMS/EXAM
■ Presents with pelvic pain, dysmenorrhea, dyspareunia, and infertility.
■ On pelvic exam, patients may have tender nodularity along the uterosacral ligament +/– a fixed, retroflexed uterus or enlarged ovaries.

Front 100

Endometriosis Dx

Back 100

DIAGNOSIS
Diagnosis can be made by the history and physical, but the gold standard is direct visualization during laparoscopy with biopsy showing endometrial
glands.

Front 101

Endometriosis treatment

Back 101

TREATMENT
Treatment depends on the patient’s symptoms, age, desire for future fertility, and disease stage.
■ If the patient’s main complaint is infertility, operative laparoscopy should be performed to excise the endometriomas.
■ If the patient’s main complaint is pain, the objective is to induce a state of anovulation:
■ For mild pain, first-line treatment is NSAIDs and/or continuous OCPs.
■ For moderate to severe pain, options include medical treatment to induce anovulation (GnRH agonists) or excision.
■ Hysterectomy with bilateral oophorectomy is curative.

Front 102

A 23-year-old woman presents to her gynecologist because she has been unable to conceive despite having attempted to do so for two years. Her
partner’s infertility workup has been . The patient was diagnosed with diabetes at age 14 but is otherwise healthy. On exam, she is found to be 5′2″ with a weight of 165 pounds, and she has acne. What would you expect to find on exam and imaging?

Back 102

The patient probably has PCOS. You would expect to find enlarged ovaries on bimanual exam and polycystic ovaries on ultrasound/CT scan.

Front 103

Polycystic Ovarian Syndrome (PCOS)

Back 103

The most common cause of female hirsutism (male-pattern hair growth). Typically affects adolescent women. The cause is unknown.

Front 104

Polycystic Ovarian Syndrome (PCOS) symptoms

Back 104

SYMPTOMS
Look for an obese woman with hirsutism, oligo- or amenorrhea, infertility, acne, and diabetes or insulin resistance.

Front 105

Polycystic Ovarian Syndrome (PCOS) Exam findings

Back 105

EXAM
■ Exam may reveal hirsutism with no evidence of cortisol or adrenal androgen excess.
■ Pelvic exam may reveal palpably enlarged ovaries.

Front 106

Polycystic Ovarian Syndrome (PCOS) Dx

Back 106

DIAGNOSIS
■ Two out of three of the following clinical signs must be present to diagnose PCOS:
■ Oligo- or anovulation.
■ Hyperandrogenism (acne, hirsutism, or elevated testosterone).
■ Polycystic ovaries.
■ An ↑ LH/FSH ratio (> 2) is also characteristic.
■ Perform a glucose tolerance test to evaluate for diabetes/hyperglycemia.

Front 107

Polycystic Ovarian Syndrome (PCOS) treatment

Back 107

TREATMENT
Treat the specific symptoms:
■ Infertility: Induce ovulation with clomiphene and/or metformin.
■ Hirsutism: Start combination OCPs to suppress ovarian steroidogenesis.
■ Hyperglycemia/diabetes: Weight loss; hypoglycemic agents.

Front 108

A 19-year-old woman who is sexually active with multiple partners presents to your clinic with vaginal pruritus and ↑ discharge. A wet mount and
KOH prep reveal no organisms. What organism is likely contributing to her vulvovaginitis?

Back 108

Chlamydia.

Front 109

Vulvovaginitis

Back 109

The most common outpatient gynecologic problem. Vulvovaginitis can be bacterial (bacterial vaginosis), fungal (Candida), or protozoal (Trichomonas
vaginalis). Figure 15-3 depicts the histologic appearance of two common causes of vulvovaginitis.

Front 110

Vulvovaginitis symptoms

Back 110

SYMPTOMS/EXAM
■ May present with ↑ vaginal discharge, a change in vaginal discharge odor, and/or vulvovaginal pruritus.
■ Perform a complete examination of the vulva, vagina, and cervix. Look for vulvar edema, erythema, and discharge.

Front 111

Vulvovaginitis Dx

Back 111

DIAGNOSIS/TREATMENT
Obtain swabs from the vagina to perform a wet mount and cultures for gonorrhea and chlamydia (see Table 15-2).

Front 112

A 28-year-old woman who found out that she was pregnant one week ago presents to the ER complaining of fevers and RLQ abdominal pain.
Her exam is significant for RLQ tenderness and no cervical motion tenderness.

What should be the next step?

Back 112

Abdominal ultrasound to look for an adnexal mass. It is too early to visualize an intrauterine gestational sac. Also, trend the patient’s β-hCG, as levels tend to
rise less in ectopic as opposed to intrauterine pregnancies. It is also important to consider nongynecologic causes.

Front 113

Ectopic Pregnancy

Back 113

Defined as any pregnancy that is implanted outside the uterine cavity. The most common location is the fallopian tube (95%). Risk factors include a history
of PID, prior ectopic pregnancy, tubal/pelvic surgery, DES exposure in utero leading to abnormal tubal development, and IUD use.

Front 114

Ectopic Pregnancy symptoms

Back 114

SYMPTOMS/EXAM
■ Patients may complain of lower abdominal or pelvic pain as well as abnormal vaginal spotting or bleeding and amenorrhea.
■ The abdomen may be tender to palpation. Bimanual exam may also reveal cervical motion tenderness and an adnexal mass.
■ A ruptured ectopic may present with unstable vital signs, diffuse abdominal pain, rebound tenderness, and shock.

Front 115

Ectopic Pregnancy Differentials

Back 115

DIFFERENTIAL
Spontaneous abortion, molar pregnancy, ruptured corpus luteum cyst, PID, ovarian torsion, appendicitis, pyelonephritis, diverticulitis, regional ileitis, ulcerative colitis.

Front 116

Ectopic Pregnancy Dx

Back 116

DIAGNOSIS
■ An ↑ β-hCG in the absence of an intrauterine pregnancy on ultrasound is highly suspicious for an ectopic pregnancy.
■ Do an ultrasound to look for an intrauterine pregnancy, an adnexal mass, or free fluid (see Figure 15-4).
■ The gestational sac may be visualized on:
■ Transvaginal ultrasound when β-hCG is approximately 1000–2000 mIU/mL, or at approximately 4–5 weeks’ GA.
■ Transabdominal ultrasound when β-hCG is > 1800–3600 mIU/mL.
■ Fetal heart motion of the embryo can be seen after 5–6 weeks’ GA.
■ Definitive diagnosis is made by laparoscopy, laparotomy, or ultrasound visualization of a pregnancy outside the uterus.

Front 117

Ectopic Pregnancy Treatment

Back 117

TREATMENT
■ For hemodynamically unstable patients, immediate surgery is required.
■ For hemodynamically stable patients:
■ Follow serial β-hCG levels closely with or without ultrasound studies.
■ Methotrexate is used for small (< 3.5-cm), unruptured ectopic pregnancies in asymptomatic women until levels are undetectable.
■ Laparoscopy or laparotomy for removal of ectopic pregnancy.
■ Expectant management is appropriate for stable, compliant patients with decreasing β-hCG levels or β-hCG < 200 mIU/mL, and if the risk of rupture
is low.
■ Prevention of ectopic pregnancies includes prevention and thorough treatment
of STDs.

Front 118

When should you be suspicious of ectopic pregnancy

Back 118

↑ β-hCG in the absence of an intrauterine pregnancy on ultrasound is suspicious for an ectopic pregnancy.

Front 119

What should occur with every woman with ectopic pregnancies

Back 119

All women with ectopic pregnancies should be typed and screened and given RhoGAM if Rh is .

Front 120

What does every woman with abdominal pain need

Back 120

Any woman with abdominal pain needs a urine pregnancy test

Front 121

Contraindications to OCP use include the following:

Back 121

■ Pregnancy.
■ Previous or active thromboembolic disease.
■ Smoking in patients > 35 years of age.
■ Undiagnosed genital bleeding.
■ Estrogen-dependent neoplasms.
■ Hepatocellular carcinoma.
■ Acute liver dysfunction.

Front 122

The long-term consequences of OCP use include

Back 122

The long-term consequences of OCP use include a ↓ in ovarian and endometrial cancers, a ↓ incidence of breast disease (but not breast cancer), ↓ menstrual
fl ow, and ↓ dysmenorrhea. OCP use also ↑ the risk of hypertension and stroke

Front 123

OTHER HORMONAL CONTRACEPTIVES
Have fewer compliance issues than OCPs. Include the following

Back 123

■ Injectable (Depo-Provera): Administered intramuscularly every three months.
■ Transdermal (Ortho Evra): A patch that is changed weekly for three weeks followed by a one-week holiday.
■ Vaginal (NuvaRing): A vaginal ring that is removed after three weeks followed by a one-week holiday.
■ Intrauterine (Mirena): See the discussion of IUDs below.

Front 124

A 36-year-old mother with a history of breast cancer presents to her gynecologist seeking a reliable, “hassle-free” birth control option. She has been
in a long-term relationship with her husband. What method would you recommend?

Back 124

A copper IUD would be optimal for this patient, since she has a contraindication to using hormonal contraceptives and is not at high risk for contracting
STDs.

Front 125

Two types of IUDs are approved for use in the United States. Both are highly effective, with > 99% efficacy during the first year of use.

Back 125

■ Levonorgestrel IUD (trade name Mirena):
■ Lasts 5 years.
■ ↓ the amount of menstrual bleeding and dysmenorrhea; thus, a good choice for the treatment of menorrhagia.
■ Side effects: Irregular menstrual bleeding or amenorrhea.
■ Copper IUD (trade name ParaGard):
■ Lasts 10 years.
■ Nonhormonal; a good choice for women who have contraindications to hormone treatment.
■ Side effects: Dysmenorrhea and ↑ menstrual bleeding.

Front 126

When should emergency contraception be taken

Back 126

Should be taken immediately after intercourse; can be taken up to five days afterward, but with decreasing effectiveness.

Front 127

What options are available for emergency contraception

Back 127

■ Options include levonorgestrel +/– estradiol.

Front 128

What is the leading cause of female infertility

Back 128

Endometriosis is the leading cause of female infertility, followed by PID.

Front 129

Infertility

Back 129

Defined as the inability of a couple to conceive after one year of unprotected intercourse. It affects 10–15% of couples. Causes include the following:
■ Male dysfunction (35%): Defects in spermatogenesis (male factor); varicoceles.
■ Female dysfunction (50%):
■ Uterine/tubal factors: Endometriosis or myomas that distort the endometrium or fallopian tubes, PID, congenital genital tract abnormalities.
■ Ovulatory dysfunction: Ovarian failure, prolactinoma.
■ Endocrine dysfunction: Thyroid/adrenal disease, PCOS.
■ Unexplained infertility and rare problems (15%).

Front 130

Infertility Dx

Back 130

DIAGNOSIS
■ Semen analysis to rule out male factors.
■ Serum FSH/LH/TSH/prolactin to rule out endocrine dysfunction.
■ Hysterosalpingography to rule out tubal and uterine cavity abnormalities.
■ Basal body temperatures or ovulation kits to rule out ovulatory dysfunction.

Front 131

Infertility treatment

Back 131

TREATMENT
■ Treat the underlying cause.
■ Fertility rates in endometriosis can be improved through laparoscopic removal of implants outside the uterine cavity.
■ Ovulation can be induced with clomiphene, but this can lead to ovarian hyperstimulation and multiple gestations.
■ For refractory cases, assisted reproductive technologies such as in vitro fertilization
can be used.

Front 132

What is premature menopause

Back 132

Premature menopause occurs before age 40 and is often due to idiopathic premature ovarian failure.

Front 133

What is Menopause

Back 133

Cessation of menstruation for > 12 months. Average age of onset is 51. Surgical menopause occurs following removal or irradiation of the ovaries.
Postmenopausal women are at ↑ risk for developing osteoporosis and heart disease.

Front 134

Menopause symptoms

Back 134

SYMPTOMS/EXAM
■ Patients may complain of menstrual irregularities, hot fl ashes, sweating, sleep disturbances, mood changes, ↓ libido, and vaginal dryness.
■ Exam may reveal vaginal dryness, ↓ breast size, and genital tract atrophy.

Front 135

Menopause Dx

Back 135

DIAGNOSIS
■ Requires one year without menses with no other known cause.
■ ↑↑ serum FSH (> 30 IU/L) is suggestive.

Front 136

Menopause treatment

Back 136

TREATMENT
■ Hormone therapy with estrogen (in woman without a uterus) or combined estrogen and progesterone (in woman with an intact uterus) can be used for short-term symptomatic relief.
■ Absolute contraindications to hormone therapy include undiagnosed vaginal bleeding, active liver disease, recent MI, recent or active vascular
thrombosis, and a history of endometrial or breast cancer.
■ Alternatives to hormone therapy include the following:
■ Vasomotor instability: Venlafaxine and some SSRIs.
■ Vaginal atrophy: Vaginal lubricants or topical estrogens.
■ Osteoporosis: Calcium, vitamin D, calcitonin, bisphosphonates (alendronate), and selective estrogen receptor modulators (raloxifene).
■ Unopposed estrogen (without progesterone therapy) can lead to endometrial hyperplasia and/or carcinoma.

Front 137

A 43-year-old mother of four presents to her primary care physician complaining of urinary leakage that has occurred during her aerobics classes and when she coughs or lifts heavy objects. These symptoms started after the birth of her last child. She wants to avoid surgery if at all possible.

What do you recommend?

Back 137

This patient has stress incontinence from a weakened pelvic floor. Kegel exercises can strengthen the pelvic floor and improve symptoms. Pessaries can also
be used to prevent embarrassing leakage.

Front 138

What is Urinary Incontinence

Back 138

Involuntary loss of urine that is a social or hygienic problem. See Table 15-3 for an outline of stress, urge, and mixed incontinence.

Front 139

Urinary Incontinence Exam & Dx

Back 139

EXAM/DIAGNOSIS
■ Voiding diaries can help quantify the frequency and volume of urine lost, the circumstances of leakage (to diagnose stress or urge types of incontinence), voiding patterns, and the amount and type of fluid taken in.
■ Patients with incontinence should have a screening neurologic exam to rule out neurologic causes.
■ A standing cough stress test can be used to diagnose stress incontinence; cystometry can be used to diagnose urge incontinence.
■ Urinary retention with overflow can be a cause of urinary incontinence and can be diagnosed with an elevated postvoid residual.

Front 140

What must be ruled out in all women complaining of urinary incontinence

Back 140

UTI must be ruled out in all women complaining of urinary incontinence

Front 141

Urinary Incontinence treatment

Back 141

TREATMENT
Table 15-3 outlines treatment measures for urinary incontinence.

Front 142

Types of Benign Breast Disorders

Back 142

Include fibrocystic change (the most common), fibroadenoma, intraductal papilloma (a common cause of bloody nipple discharge), duct ectasia,
fat necrosis, mastitis, and breast abscess. See Table 15-4 for a list of common examples.