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402 Cards in this Set

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hCG source
placental synsytiotrophoblast;
in blood 10 days after fertilization
peaks 9-10weeks, falling to plateau in 20-22 weeks
hCG structure
alpha subunit similar to LH, FSH, thyrotropin
beta subunit is specific
hCG functions
maintain corpus luteum production of progesterone until placenta
regulate steroid synthesis in placenta and fetal adrenals
stimulate testosterone production in fetal male testes
excess hCG
twin pregnancy
hydatiform mole
choriocarcinoma
embryonal carcinoma
low hCG
ectopic pregnancy
threatened abortion
missed abortion
human placental lactogen
similar to GH and prolactin
levels rise with placental growth
antagonizes insulin, predisposes to gestational diabetes
if low --> threatened abortion, intrauterine growth restriction
progesterone source
6-7 weeks --> corpus luteum
7-9 weeks --> corpus luteum and placenta
>9 weeks --> increasingly the placenta
progesterone functions
early pregnancy --> induces endometrial secretory changes for blastocyst implantation
late pregnancy --> induces immune tolerance for pregnancy and prevents myometrial contractions
stimulates the development of milk-producing alveolar cells
estrogen varieties
estradiol (non-pregnant)
estriol (pregnancy)
estrone (menopause)
estradiol
non-pregnant reproductive years
androgens from follicular theca cells diffuse to granulosa cells
aromatase in granulosa cells converts androgens to estradiol
promotes the growth of breast ducts
antagonizes prolactin in breast
estriol
main estrogen in pregnancy
DHEA-S from fetal adrenals is converted to estriol by placental sulfatase
promotes the growth of breast ducts
antagonizes prolactin in breast
estrone
menopause estrogen
adrenal androstenedione is converted by peripheral adipose tissue to estrone
physiologic skin changes in pregnancy
striae gravidarum stretch marks in genetically predisposed
spider angiomata and palmar erythema from increased vascularity
Chadwik sign --> bluish vagina and cervix from increased vascularity
linea nigra --> hyperpigmentation between pubis and umbilicus
chloasma --> blotchy pigmentation of nose and face
physiologic cardiovascular changes in pregnancy
arterial BP --> decreased (increase is never normal)
femoral venous pressure --> increased
SVR --> decreased
CO --> increases up to 50% by 20 weeks (increased HR and SV)
plasma volume --> increased up to 50% by 30 weeks
systolic ejection murmur is normal; diastolic murmurs are abnormal
physiologic hematologic changes in pregnancy
RBC increases by 30% but there's dilutional effect (not anemia)
WBC increase up to 16,000
ESR increases
coagulation factors VII, VIII, IX, X increase --> hypercoagulable state
physiologic GI changes in pregnancy
decreased gastric motility --> increased stomach residual volume --> gravid uterus stomach displacement --> can predispose to aspiration pneumonia with general anesthesia

decreased colonic motility --> fluid absorption --> constipation
physiologic pulmonary changes in pregnancy
all volumes are decreased except tidal volume which increases up to 40% --> compensated respiratory alkalosis
physiologic renal changes in pregnancy
kidney hypertrophy
increased ureteral diameter (more on the right)
GFR and creatinine clearance increase
glucose treshold decreases to 155mg/dL --> glucosuria
urine protein is unchanged
physiologic endocrine changes in pregnancy
pituitary increased by 100% --> predisposes to Sheehan from postpartum hypotension
adrenals are unchanged by cortisol increases 2-3x
thyroid size increases 15%, TBG and total T3/T4 increase
fetal circulation shunts
ductus venosus --> from umbilical vein to inferior vena cava (byoasses liver)
foramen ovale --> from right to left atrium
ductus arteriosus --> from pulmonary artery to descending aorta
prolactin
from anterior pituitary stimulates milk production
oxytocin
from posterior pituitary causes milk ejection in response to suckling
postconception week 1
day 0 --> fertilization in the distal oviduct
day 3 --> entry of morula into uterine cavity
day 6 --> implantation of the blastocyst onto endometrium, formation of trophoblast (placenta) and embryonic cells
postconception week 2
bilaminar germ disk with epiblast and hypoblast
invasion of maternal sinusoids by syncytiotrophoblast
beta-hCG passes to maternal blood
postconception week 3
trilaminar germ disk
postconception weeks 4-8
organ formation
risk of teratogenesis
paramesonephric duct
Mullerian duct needs no hormonal stimulation to become female internal organs
Mullerian inhibitory factor produced by Sertoli cells in males causes Mullerian duct involution
mesonephric duct
Wolffian duct needs testosterone from Leydig cells to develop into male reproductive system
absence of testosterone in females causes Wolffian involution
female external genitalia
needs no hormonal stimulation to form
male external genitalia
dihydrotestosterone produced by 5-alpha reductase from testosterone is needed for formation
genetic male with androgen receptor absence
Wolffian duct doesn't develop
external genitalia will not develop
category A teratogen
controlled studies show no risk
acetaminophen, thyroxine, folic acid, magnesium sulfate
category B teratogen
no evidence of risk in humans despite risks in animals
penicillins, cephalosporins, insulin, pepcid, reglan, paxil, prozac, benadryl, dramamine
category C teratogen
risk cannot be ruled out, controlled studies are lacking in humans
codeine, methadone, AT, beta blockers, prilosec, heparin, protamine, robitussin, sudafed
category D teratogen
postive evidence of risk but potential benefits may outweight the risks
aspirin, valium, tetracycline, depakote, lithium
category X teratogen
contraindicated in pregnancy
isotretinoin, danocrine, pravachol, coumadin, cafergot
infectious teratogens
chlamydia, gonorrhea --> neonatal eye and ear infections
rubella -->
CMV -->
herpes -->
syphilis -->
toxoplasmosis -->
ionizing radiation teratogenicity
no risk with exposure <5 rads (diagnostic procedures)
risk proportional to doses above 20rads
chemotherapy teratogenicity
risk in the first trimester
environmental teratogens
alcohol --> alcohol fetal syndrome
tobacco --> IUGR and preterm delivery
cocaine --> placental abruption, IUGR, preterm delivery
marijuana --> preterm delivery
fetal alcohol syndrome
IUGR
midfacial hypoplasia
developmental delay
short palpebral fissures
long filtrum
joint anomalies
cardiac defects
diethylstilbestrol syndrome
category X teratogen
T-shpaed uterus
vaginal adenosis
predisposition to vaginal clear cell carcinoma
cervical hood
incompetent cervix
preterm delivery
fetal hydantoin syndrome
due to Dilantin, category D teratogen
IUGR
craniofacial dysmorphism
mental retardation
microcephaly
nail hypoplasia
heart defects
isotretinoin as teratogen
category X teratogen
congenital deafness
microtia
CNS defects
congenital heart defects
lithium as teratogen
category D teratogen
produces Ebstein's anomaly (right heart defect)
streptomycin as teratogen
VIII nerve damage
hearing loss
tetracycline as teratogen
category D teratogen
teeth discoloration after 4th month
thalidomide as teratogen
category X teratogen
phocomelia
limb reduction defects
ear/nasal anomalies
cardiac defects
pyloric or duodenal stenosis
trimethadione as teratogen
facial dysmorphism
cardiac defects
IUGR
mental retardation
valproic acid as teratogen
class D teratogen
neural tube defects, spina bifida
cleft lip
renal defects
warfarin as teratogen
category X teratogen
chondrodysplasia
microcephaly
mental retardation
optic atrophy
indications for genetic counseling
advanced maternal age >35
multiple fetal losses
previous child with congenital defects or neonatal death
pregnancy or fetal losses
family history of birth defects or mental retardation
abnormal prenatal tests (triple marker screen, sonogram)
parental aneuploidy
Turner syndrome
45X due mostly to paternal loss of X
98% abort spontaneously
ultrasound shows nuchal skinfold thinkening and cystic hygroma
survivors have primary amenorrhea, web neck, streak gonads, absence of secondary sex features, infertility, broad chest, neck webbing, aortic coarctation
Klinefelter syndrome
47XXY
tall stature
testicular atrophy
gynecomastia
azoospermia
truncal obesity
learning disorders and low IQ
Down syndrome
trisomy 21
short stature
mental retardation
endocardial cushion defects
short stature
short neck
typical facial appearance
duodenal atresia
Edward syndrome
trisomy 18
profound mental retardation
rocker-bottom feet
clenched fists
1 year survival is 40%
Patau syndrome
trisomy 13
profound mental retardation
cleft lip with palate
holoprosencephaly
1 year survival is 40%
vacuum curetage
90% of induced abortions
performed before 13 weeks
prophylactic antibiotics, conscious sedation, paracervical block for pain relief
dilation and curettage (D&C)
complications --> endometritis, retained products of conception
medical abortion
mifepristone (progesterone antagonist) and misoprostol (prostaglandin E1)
must be used in first 63 days of amenorrhea
85% of patients will abort within 3 days
second trimester abortion methods
dilation & evacuation
labor induction with hypertonic solutions of prostaglandins
spontaneous abortion definition
bleeding that occurs before 12 weeks gestation
MCC is fetal in origin
etiology of spontaneous abortion
gross chromosomal abnormalities
mendelian defects
antiphospholipid syndrome
spontaneous abortion general measures
speculum exam to rule out vaginal or cervical lesions as cause of bleeding
molar and ectopic pregnancy should be ruled out
RhoGAM administration to all Rh-negative gravidas who undergo D&C
missed abortion
sonogram finding of nonviable pregnancy
no vaginal bleeding, uterine cramping or cervical dilation
management: scheduled D&C OR conservative management awaiting completion OR misoprostol
threatened abortion
sonogram finding of a viable pregnancy with vaginal bleeding but no cervical dilation
management: observation
inevitable abortion
vaginal bleeding and uterine contractions leading to cervical dilation but no POC
management: emergency suction D&C to prevent further blood loss
incomplete abortion
vaginal bleedingm uterine contractions, cervical dilation and some POC passes
management: emergency suction D&C to prevent further blood loss
completed abortion
vaginal bleeding and uterine contractions with all POC passed
confirm by sonogram showing no intrauterine contents
management: conservative if previous intrauterine pregnancy had been diagnosed or serial beta-hCG weekly until negative to rule out ectopic pregnancy
fetal demise definition
in utero death of fetus after 20 weeks
antenatal demise --> occurs before labor
intrapartum demise --> after onset of labor
fetal demise complications
DIC if fetal demise >2weeks (dead fetus releases tissue thromboplastin)
prolonged grief resolution
fetal demise risk factors
MCC is idiopathic
antiphospholipid syndrome
maternal diabetes
maternal trauma
severe maternal isoimmunization
fetal aneuploidy
fetal infection
fetal demise presentation and diagnosis
before 20 weeks --> uterine fundus less than dates
after 20 weeks --> mother reports absence of fetal movements
diagnosis --> ultrasound showing no fetal cardiac activity
fetal demise management
exclude DIC --> platelets, d-dimer, fibrinogen, PT, PTT; if present then inmediate delivery
if DIC not present --> deferred delivery or conservative management with weekly coagulation tests
delivery: if <20 weeks or no autopsy --> D&E; if >20 weeks or autopsy --> prostaglandins for induction of labor
ectopic pregnancy presentation
secondary amenorrhea
unilateral abdominal/pelvic pain
vaginal bleeding
unilateral adnexal tenderness
cervical motion tenderness
if ruptured --> signs of hypotension, abdominal guarding and rigidity
ectopic pregnancy with (+)b-hCG differential diagnosis
if positive beta-hCG -->
threatened abortion
incomplete abortion
ectopic pregnancy
hydatiform mole
ectopic pregnancy risk factors
pelvic inflammatory disease
tuboplasty/ligation
DES
idiopathic
ectopic pregnancy diagnosis
presumption of ectopic pregnancy --> beta-hCG > 1,500 mIU + no intrauterine pregnancy with vaginal sonogram
repeat beta-hCG & sonogram in 2-3 days
if beta-hCG hasn't doubled --> ectopic pregnancy
else --> IUP; exclude threatened abortion or hydatiform mole
ectopic pregnancy management
ruptured ectopic --> emergency laparotomy to stop bleeding
unruptured ectopic --> methotrexate (if criteria met) or laparoscopy/laparotomy
if methotrexate or salpingostomy --> weekly beta-hCG to confirm resolution of pregnancy
Rh-negative women --> RhoGAM
methotrexate criteria for ectopic pregnancy
pregnancy mass <3.5cm diameter
absence of fetal heart motion
beta-hCG <6,000mIU
no history of folic acid supplementation
chorionic villus sampling
catheter is placed into placental tissue without entering amniotic fluid at 10-12 weeks gestation
chorionic villi are aspirated
tissue is sent for karyotyping
amniocentesis
performed after 15 weeks
needle is placed under ultrasound guidance and amniotic fluid is aspirated
amniocytes are sent for karyotyping
neural tube defects are screened with alphafetoprotein and acetylcholinesterase
pelvic relaxation
uterine prolapse (grades I-IV)
cystocele
rectocele
enterocele
urinary incontinence
cystocele
postmenopausal woman
anterior vaginal wall protrussion
urinary incontinence
diagnosis --> pelvic exam
rectocele
postmenopausal woman
posterior vaginal wall protrussion
digitally assisted removal of stool
diagnosis --> pelvic exam
medical management of pelvic relaxation
used in minor relaxation
Kegel exercises --> voluntary contractions of pubococcygeus muscle
estrogen replacement --> in postmenopausal women
pessaries --> objects inserted into vagina to elevate pelvic structures
surgical management of pelvic relaxation
used when medical management fails
vaginal hysterectomy with anterior and posterior colporrhaphy (vaginal repair)
pharmacology of urinry incontincence
alpha adrenergeic --> contract urethra; ephedrine, imipramine, estrogens; phenoxibenzamine is antagonist
beta adrenergic --> relax detrusor muscle; flavoxate, progestins
cholinergic --> contract detrusor muscle; bethanecol, neostigmine; anticholinergics are oxybutynin, propantheline
cystometry
urinary catheter empties bladder then infuses saline; measures -->
residual volume --> normal 50mL
sensation of fullness --> normal 200-225mL
urge to void --> normal 400-500mL
sensory irritative incontinence
involuntary detrusor contractions stimulated by irritation from infections, stones, tumor, foreign body
presentation --> loss of urine with frequency, urgency and dysuria, suprapubic tenderness
diagnosis --> urinalysis and urine culture or cytoscopy; cystometry is usually unnecessary
management --> antibiotics for infections; cytoscopy for stones, foreing bodies and tumors
stress incontinence
from rises in intraabdominal pressure
presentation --> involuntary loss of urine with coughing or sneezing, no urine loss at night
exam --> cystocele may be present and Q-tip test is positive (rotates >30degrees)
studies --> urinalysis and culture are normal; cystometry is normal without detrusor contractions
management --> Kegel or estrogen; urethropexy or tension-free vaginal tape
motor urge hypertonic incontinence
idiopathic detrusor contractions that can't be suppressed volutarily
presentation --> loss of urine, cannot suppress urge to void, day or night
tests --> urinalysis and culture are normal; residual volume is normal but there are involuntary detrussor contractions
management --> anticholinergics and NSAIDs
overflow hypotonic incontinence
hypotonic bladder does not empty until theres excess pressure;
etiology --> denervated bladder from diabetic neuropathy or multiple sclerosis, anticholinergics
presentation --> urine loss day and night with no detrussor contractions; decreased pudendal nerve sensation
tests --> urinalysis and culture normal or infection; markedly increased residual volume without detrussor contractions
management --> self-catheterization; cholinergics, alpha blockers
bypass fistula incontinence
presentation --> history of radical pelvic or radiation surgery, continuous urine loss day and night
diagnosis --> intravenous pyelogram shows dye leakage from urinary tract fistula
management --> surgical repair
vaginal discharge diagnostic tests
speculum exam --> looking for inflammation and characteristics of discharge
vaginal pH --> normal is <4.5; nitrazine paper turns yellow when normal or dark when high pH
KOH slide --> two drops of vaginal discharge + saline + KOH are analyzed on microscope
bacterial vaginosis
high pH replaces normal flora lacbacilli
presentation and diagnosis --> fishy odor, no itching, pH>4.5, thin grayish discharge, whiff+ on KOH, clue cells on wet mount
management --> metronidazole (safe in pregnancy) or clindamycin; orally or vaginally
trichomonas vaginitis
STD; protozoan resides in seminal fluid
presentation and diagnosis -->itching, burning, pain with intercourse, green discharge, inflammation seen, erythematous cervix, pH>4.5, trichomonads and WBCs on saline
management --> oral metronidazole orally for patient and partner
candida yeast vaginitis
presentation and diagnosis --> itching, burning, pain with intercourse, normal pH, white discharge, inflammation seen, pseudohyphae on KOH
management --> single oral dose of fluconazole or vaginal azole creams
physiologic discharge
due to excess estrogen
presentation and diagnosis --> watery vaginal discharge, no itching, no inflammation, normal pH, absence of pathogens on wet mount
management --> contraception with progestins
vaginal discharge with normal pH
candida, physiologic discharge
vaginal discharge with high pH
bacterial vaginosis, trichomonas
grayish discharge
bacterial vaginosis
white discharge
candida
green discharge
trichomonas
watery discharge
physiologic discharge
differentail diagnosis of vulvar itching
vulvar carcinoma
STDs
benign vulvar dystrophy
malignant cancer
all lesions should have biopsy
vulvar dystrophy
squamous hyperplasia --> whitish, firm, cartilaginous lesions with thick kertain and epithelial proliferation on microscope; management is fluorinated corticosteroid cream

lichen sclerosis --> bluish-white papula that can coalesce into white plaques and show epithelial thinning; management is clobetasol cream
premalignant vulvar lesions
squamous dysplasia --> white, red or pigmented multifocal lesions with epithelium atypia not reaching BM; management is surgical excision

CIS --> same presentation with more atypia but not reaching the BM; management is laser vaporization
malignant vulvar lesions
squamous cell carcinoma --> most common; associated with HPV
melanoma --> 2nd most common; any dark or black lesion should be biopsied; prognosis related to depth of invasion
Paget disease --> red vulvar lesion
management of malignant vulvar lesions
radical vulvectomy with or without lymphadenectomy
benign vulvar lesions
molluscom contagiousum --> spontaneously regressing umbilicated tumors; observation, curettage, cryo
condylomata acuminata --> HPV 6 & 11 cauliflower lesions
Bartholin cyst --> aspiration yields sterile fluid
cervical polyps
presentation --> vaginal bleeding and smooth red or purple fingerlike projections from cervical canal
diagnosis --> biopsy shows mildly atypical cells
management --> twisting or surgical string for the polyp; electrocautery or laser for the base
nabothian cysts
mucus-filled cyst on cervix surface
presentation --> asymptomatic small white pimpli-likeelevation palpated or seen by colposcopy
management --> none necessary but can be removed by electrocautery or cryotherapy
cervicitis
presentation --> mucopurulent cervical discharge without pelvic tenderness or fever
diagnosis --> cervical culture shows chlamydia or gonorrhea
management --> oral azythromycin single dose or doxycycline 7 days
premalignant cervical lesions
are asymptomatic and 15% can progress to cancer in 8-10 years
65% regress; 20% stay the same
due to HPV 16, 18, 30s
risk factors for HPV --> early age of intercourse, multiple partners, cigarette smoking, immunosuppression
what is a pap smear
exfoliative cytology
best screening test for premalignant lesions
one specimen from T-zone and one from endocervix
conventional method --> samples are smeared and fixated onto slide
liquid-based method --> samples are rinsed into a solution
pap smear screening
start 3 years after onset of sexual intercourse or at age 21
discontinue at age 70 after >3 consecutive negative tests
if under age 30 --> screen annually with conventional or every 2 years with liquid-based
if over 30 --> screen every 2-3 years if >3 negative pap smears
pap smear classification
negative
ASC --> atypical squamous cells; undertermined significance or cannot exclude HSIL
LSIL --> low-grade squamous intraepithelial lesion; biopsy shows HPV, mild dysplasia or CIN 1
HSIL --> high-grade squamous intraepithelial lesion; biopsy shows moderate-severe dysplasia or CIN 2-3
cancer --> biopsy will show invasive cancer
ASCUS pap smear
results from inflammatory or atrophic lesions or the initial stages of HPV infection
10-15% of ASCUS paps can have a significant premalignant lesion
management --> repeat cytology in 3-6 months and HPV DNA testing (reliable patients) or colposcopy+biopsy (unreliable patients)
if high risk HPV DNA test --> colposcopy+biopsy
colposcopy
performed if there's high risk results from HPV DNA test
satisfactory or adequate --> entire T-zone is visualized and no lesions dissapear into endocervix
unsatisfactory or inadequate --> entire T-zone cant be visualized
colposcopy includes endocervical curettage and ectocervical biopsy
cone biopsy
indications:
pap smear is worst than colposcopy biopsy
abnormal endocervical curettage
lesion in endocervical canal
biopsy shows microinvasive carcinoma
cervical dysplasia management according to histology
CIN 1 --> repeat Pap in 6-12 months OR colposcopy+Pap in 12 months OR HPV DNA in 12 months
CIN 1, 2, 3 --> ablation with cryotherapy, laser or electrofulguration
CIN 1, 2, 3 --> excision by LEEP or cold-knife conization
biopsy confirmed recurrent CIN 2 or 3 --> hysterectomy
all ablations or excisions require repeat Pap, colposcopy, HPV DNA every 4-6 months for 2 years
invasive cervical cancer presentation and diagnosis
postcoital vaginal bleeding, irregular vaginal bleeding, lower extremity pain and edema
cervical biopsy --> initial diagnostic test
metastatic workup --> do if biopsy is positive; pelvic exam, chest x-ray, IV pyelogram, cystoscopy, sigmoidoscopy
CT or MRI are not used for staging
invasive cervical cancer management
stage Ia1 --> <=3mm, simple hysterectomy
stage Ia2 --> 3-5mm, modified radical hysterectomy
stage Ib --> radical hysterectomy
stages II-IV --> radio and chemo
follow-up --> pap every 3months for 2 years; then every 6 months for 3 years
cervical neoplasia in pregnancy
all abnormal pap smears should be followed by colposcopy+biopsy
no ECC is performed
cervical neoplasia in pregnancy management
CIN --> follow with Pap+colposcopy evrery 3 months during pregnancy; treat postpartum
microinvasion --> do cone biopsy; if confirmed, then treat postpartum
invasive cancer --> if diagnosis before 24 weeks then radical hysterectomy or radio; if after 24 weeks then cesarean at 32-33 weeks + definitive treatment
HPV vaccine
quadrivalent for types 6, 11, 16, 18 (70% of cancers and 90% of warts)
uses noninfectious particles
recommended to all women 8-26 with target age 11-12
do not test for HPV before vaccine
continue regular Paps
not recommended for pregnant, lactating or immunosuppressed
mullerian anomalies
hypoplasia/agenesis
unicornuate uterus
didelphys uterus
bicornuate uterus
septate uterus
arcuate uterus
DES uterus
uterine hypoplasia/agenesis
may lack vagina or any part of uterus except fundus
associated with urinary tract anomalies
unicornuate uterus
one Mullerian duct does not develop or develops incompletely
the incompletely developed half uterus lacks a cavity connecting to vagina which leads to pain during menses in teenagers
may have pregnancy in the bad uterus but 90% of them rupture
didelphys uterus
double uterus from failure of Mullerians to fuse
may have a single or two cervix or vaginas
bicornuate uterus
most common
failure of Mullerians to fuse at the top results in two horns sharing a cervix or two bodies sharing a cervix
septate uterus
Mullerians fused but theres no degeneration of median septum
external shape appears normal
arcuate uterus
small midline indentation at the fundus
does not have negative effects on pregnancy
DES uterus
daughters of mothers exposed to DES during pregnancy
may have hypoplastic uterus, T-shaped cavity and/or cervical defects
leiomyoma presentation
most common benign uterine tumor; outgrowth of the myometrium
intramural --> most common location within the wall of the uterus
submucosal --> beneath endometrium and can distort uterine cavity; can have meno/metro or menometrorrhagia
subserosal --> beneath the serosa and can distort the external contour and pressure the bladder, rectum or ureters
leiomyoma natural history
slow growth --> small, grow slowly and cause no symptoms except if they are massive
rapid growth --> estrogen receptors are increased and result in rapid growth specially during pregnancy
degeneration --> the size is more than blood supply resulting in ischemic with acute pain requiring hospitalization and narcotics
shrinkage --> when estrogen levels fall the leiomyoma shrinks
leiomyoma diagnosis
pelvic exam --> enlarged asymetric, nontender uterus in absence of pregnancy
sonography --> traditional for intramural or subserosal or with saline infusion for submucosal
hysteroscopy --> for submucosal myomas
confirmation of diagnosis is made by histologic exam of excised tissue
leiomyoma management
observation --> most can be managed conservatively
presurgical shrinkage --> leuprolide for 3-6 months results in 60-70% shrinkage
myomectomy --> done to conserve fertility; subsequent pregnancies should be delivered by cesarean
embolization --> catheter injects microspheres which cause ischemia and necrosis of myoma
hysterectomy --> if patient has completed childbearing
adenomyosis presentation
ectopic endoemtrial glands in myometrium
presents with secondary dysmenorrhea or menorrhagia, symmetrical diffuse uterine enlargement and tenderness during menses
adenomyosis diagnosis
mostly made clinically
ultrasound or MRI shows diffusely enlarged uterus with cystic areas in myometrium
confirmation is by histology
ademyosis management
medical --> levonorgestrel intrauterine system decreases menstrual bleeding
hysterectomy --> definitive treatment
differential diagnosis for enlarged non-pregnant uterus
leiomyoma --> asymmetric, firm, nontender
adenomyosis --> symmetric, soft, tender
differential diagnosis of postmenopausal bleeding
endometrial carcinoma (most important), vaginal or endometrial atrophy (most common), postmenopausal hormone replacement
endometrial cancer risk factors
unoppossed estrogen occurs in
obesity
hypertension
diabetes
nulliparity
late manopause
chronic anovulation (polycystic ovarian disease)
endometrial cancer diagnosis
endometrial sampling
D&C if cervical stenosis is present
hysteroscopy --> rules out cervical or endometrial polyps
ultrasound --> endometrial lining should measure <5mm thick in postmanopause
endometrial cancer management
if negative histology from sampling --> diagnosis is atrophy treated with estrogen/progesterone replacement
if positive histology from sampling --> adenocarcinoma is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic/para-aortic lymphadenectomy; it may also require radio and chemo postoperative
endometrail hyperplasia
may cause bleeding; cells have no atypia; treat with progestin
ovarian cyst differential diagnosis
pregnancy (most common)

complex masses -->
dermoid cyst
benign cystic hematoma
endometrioma
tubo-ovarian abscess
ovarian cancer
ovarian cyst presentation and diagnosis
pelvic mass in reproductive years
negative betahCG (rules out pregnancy)
sonogram shows fluid-filled ovarian simple cyst
ovarian cyst management
follow-up exam in 6-8 weeks for resolution
alert patient of possibility of acute onset pain from torsion
if >7cm or prior steroid contraception --> laparoscopy
ovarian hyperthecosis pathophysiology
nests of active luteinized cells in ovarian stroma; peripheral estrogen is increased which leads to excess androgen production by ovaries; risk of endometrial hyperplasia and carcinoma are increased due to high estrogens
ovarian thecosis presentation
obesity
less severe hirsutism than PCOS
virilization (clitoral enlargement, balding, deep voice, male habitus)
amenorrhea or irregular/anovulatory cycles
can occur in postmenapause unlike PCOS
ovarian hyperthecosis management
oral contraception suppresses androgen production and free androgens
luteoma of pregnancy
non-neoplastic tumor-like mass that regresses spontaneously
asymptomatic
found incidentally
hormonally active and can produce maternal and fetal hirsutism and virilization
theca lutein cysts
benign neoplasm caused by excess FSH and beta-hCG
associated with twins and molar pregnancies
regresses spontaneously
prepubertal pelvic mass presentation and work-up
presents with sudden onset of acute abdominal pain in prepubertal female

serum tumor markers for germ cell tumors:
LDH --> dysgerminoma
beta-hCG --> chroriocarcinoma
alpha-fetoprotein --> endodermal sinus tumor
prepubertal pelvic mass diagnosis and management
if simple cyst --> diagnose with laparoscopy
if complex mass --> diagnose with laparotomy

if benign --> cystectomy+annual follow-up (pelvic exam+tumor markers)
if malignant --> unilateral S&O, staging and chemo
premenopausal complex mass
most common is dermoid cyst (benign cystic teratoma)
also endometrioma, tubo-ovarian abscess, ovarian cancer
b-hCG rules out pregnancy; ultrasound rules out simple mass (ovarian cyst)
manage with cystectomy or oophorectomy
benign cystic teratoma
complex mass with calcifications on ultrasound
ovarian torsion
presumptive diagnosis --> abrupt unilateral pelvic pain, b-hCG-, adnexal mass on ultrasound
management --> untwist ovary; if revitalization then cystectomy; if necrosis then oophorectomy
ovarian cancer presentation
postmenopausal adnexal mass
ovarian cancer risk factors
BRCA1 gene
positive family history
high number of lifetime ovulations
perineal talc powder

protective factors --> oral contraceptives, chronic anovulation, brest feeding, short reproductive life
ovarian cancer diagnosis
screening --> bimanual pelvic examination (large, solid, irregular, fixed)
tumor markers --> CEA, CA-125, LDH, AFP, hCG, testosterone
abdominal pelvic CT or pelvic ultrasound
barium enema to rule out diverticulosis
IV pyelogram for urinary tract lesions
types of ovarian tumors
epithelial --> older women; ovarian cancers (serous, mucinous, Brenner, endometrioid, clear cell)
germ cell --> younger women; dysgerminoma, endodermal, teratoma, choriocarcinoma
stromal --> granulosa-theca cells, Sertoli-Leydig cell
metastatic --> from other primary sites (endometrium, GI, breast, krukenberg)
serous ovarian carcinoma
postmenopausal woman, pelvic mass, high CEA or CA-125
choriocarcinoma
postmenopausal woman, pelvic mass, high hCG
Sertoli-Leydig tumor
postmenopausal pelvic mass, masculinization, high testosterone
endometrial carcinoma metastatic to ovaries
postmenopausal woman with bilateral pelvic masses
postmenopausal bleeding
enlarged uterus
CEA or CA-125
serous ovarian cancer
hCG as tumor marker
choriocarcinoma (ovarian germ cell tumor)
testosterone as tumor marker
Sertoli-Leydig cell ovarian stromal tumor
LDH as tumor marker
dysgerminoma
AFP as tumor marker
endodermal sinus germ cell tumor (ovary)
ovarian cancer management
laparotomy or laparoscopy with unilateral salpingo oophorectomy with histology during surgery
if benign --> USO is enough or TAH+BSO
if malignant --> TAH+BSO, omentectomy and bowel ressection if necessary + postop chemo
benign gestational neoplasia types
hydatiform mole
complete --> empty egg, paternal X, 46XX, fetus absent, grape-like vesicles
incomplete --> normal egg, maternal and paternal X, 69XXY, fetus nonviable
malignant gestational neoplasia types
nonmetastatic --> uterus only, 100%cure
good prognosis --> metastasis to pelvis or lung, 95% cure, single agent chemo
poor prognosis --> metastasis to brain or liver, 65% cure, combo chemo
gestational trophoblastic neoplasia presentation
bleeding prior to 16 weeks
passage of vesicles
hypertension
proteinuria
no fetal heart tones
hyperthyroidism
fundus larger than dates
gestational trophoblastic neoplasia diagnosis
snowstorm ultrasound shows homogenous intrauterine echoes without sac or fetus
gestational trophoblastic neoplasia management
1) baseline beta-hCG
2) chest x-ray to rule out lung metastasis
3) suction D&C
4) oral contraceptives during follow-up

if benign --> weekly b-hCG until negative for 3 consecutive weeks, then monthly until negative for 12 months
if b-hCG does not lower --> brain, thorax, abdominal and pelvic CTs for metastasis
if good prognosis metastatic --> single agent chemo + 1 year follow-up
if poor prognosis metastatic --> multiple chemo + weekly b-hCG then monthly then every three months (5 years)
cercivitis
presentation --> mucopurulent cervical discharge, without pelvic tenderness or fever
diagnosis --> nucleic acid amplification tests of cervical discharge or urine; normal WBCs and ESR
management --> single oral dose of cefixime and azithromycin
acute salpingo-oophoritis presentation and diagnosis
bilateral lower abdominal/pelvic pain
mucopurulent cervical discharge
cervical motion tenderness
high WBCs and ESR
acute salpingo-oophoritis management
certain diagnosis and no evidence of systemic infection or absecess --> ofloxacin+metronidazole 14 days
uncertain diagnosis, nulligravida, evidence of abscess or fever --> inpatient, IV cefoxitin or cefotetan + IV doxy
lower abdominal-pelvic pain differential diagnosis
acute salpingo-oophoritis
adnexal torsion
ectopic pregnancy
appendicitis
endometriosis
diverticulitis
Crohn
ulcerative colitis
tubo-ovarian abscess presentation
sepsis (tachycardia, hypotension, high fever)
severe lower abodominal-pelvic pain
peritoneal guarding and rigidity
nausea, vomit
adnexal masses may be palpated
tubo-ovarian abscess diagnosis
positive cervical cultures for chlamydia or gonorrhea
positive blood cultures for gram-
pus on culdocentesis
high WBCs and ESR
sonogram or CT show bilateral complex masses
differential diagnosis of sepsis+lower abdominal-pelvic pain
tubo-ovarian abscess
septic abortion
diverticular abscess
appendiceal abscess
adnexal torsion
tubo-ovarian abscess management
IV clindamycin and gentamicin
if no change in 72 hours or abscess rupture --> laparotomy and consider TAH+BSO
chronic PID
chronic bilateral abdominal/pelvic pain
no cervical discharge
cervical motion tenderness
negative cultures
normal WBCs and ESR
sonography may show bilateral cystic pelvic masses

diagnosis --> laparoscopic visualization of pelvic adhesions
management --> lysis of tubal adhesions or if unremitting TAH+BSO
primary dysmenorrhea Vs. secondary dysmenorrhea
primary --> teenagers, absence of pelvic pathology
secondary --> mature women, presence of pelvic pathology (endometriosis, adenomyosis)
primary dysmenorrhea
recurrent lower abdominal pain during menstrual periods in a teenager with absence of pelvic pathology
due to excess prostaglandin F2
treat with NSAIDs (first line) or oral contraception (2nd line)
endometriosis presentation and diagnosis
pelvic-abdominal pain
dyspareunia
painful bowel movements
infertility
exam --> cul-de-sac adhesions, uterosacral ligament nodularities, enlarged adnexa
lab --> normal WBCs and ESR, CA-125 may be elevated
diagnosis --> laparoscopy
endometriosis management
medical --> leuprolide (DOC), medroxyprogesterone, testosterone derivative
surgical --> laparoscopic lysis of tubal adhesions, cystectomies, laser vaporization or TAH+BSO
chancroid
painful ulcer with ragged edges due to Haemophilus ducreyi
confirm diagnosis with culture
treat with single dose azithromycin, single dose IM ceftriaxone or erythromycin 7 days
lymphogranuloma venereum
due to chlamydia trachomatis
painless vesiculopustular vaginal eruption that spontaneously heals
can have perirectal adenopathy, absecesses and fistulas within weeks
diagnosis --> postitive culture from pus aspirated from lymph node
management --> doxycylcline or erythromycin for 3 weeks
granuloma inguinale
due to calymmatobacterium granulomatis
painless ulcer with granulation tissue and no lymphadenopathy
diagnosis --> microscopicexam shows donovan bodies
management --> doxycycline or TMP-SMX 3 weeks
condyloma acuminatum
HPV 6, 11
generally asymptomatic but clinical lesions in 30%
pedunculated, soft papule turns into cauliflower lesion
management --> small lesions are treated topically with podophyllin, trichloroacetic acid; larger lesions with cryo, laser or surgical excision
mucopurulent discharge
chlamydia trachomatis (cervical), gonorrhea (cervical and vulvovaginal)
STDs with ulcers
chancroid (painful, ragged)
granuloma inguinale
genital herpes (painful, smooth)
lymphogranuloma venerreum
syphilis
STDs without ulcers
chlamydia
HPV
gonorrhea
HBV
HIV
ragged soft edge inflamed painful vaginal ulcer
chancroid
groove sign
lymphogranuloma venereum
beefy red painless vaginal ulcer
granuloma inguinale
rolled, hard edges, painless vaginal ulcer
syphilis
smooth edge inflamed painful vaginal ulcer
herpes
gonorrhea
vulvovaginal and cervical mucopurulent discharge
if cervicitis or PID --> pelvic pain, cervical motion tenderness, etc…
if disseminated --> petechial skin lesions, septic arthritis
management --> single dose cefixime + single dose azithromycin
estrogen-mediated effects of oral contraception
fluid retention
accelerated cholelithiasis
increased hepatic proteins
healthy lipid profile changes
progestin-mediated effects of oral contraception
mood changes and depression
androgenic --> weight gain, acne
unhealthy lipid profile changes
absolute contraindications of oral contraception
pregnancy
acute liver disease
history of vascular disease (DVT, CVA, SLE)
hormonally-dependant breast cancer
smoker >35y/o
uncontrolled hypertension
migraines with aura
diabetes
known thrombophilia
relative contraindications of oral contraceptives
migraines
depression
diabetes
chronic hypertension
hyperlipidemia
premanarchal vaginal bleeding differential diagnosis
ingestion of estrogens
foreign body (MCC)
cancer of vagina or cervix
pituitary or adrenal tumor
ovarian tumor
sexual abuse
idiopathic precocious puberty
premenarchal vaginal bleeding diagnosis
pelvic exam under sedation for foreign bodies, sexual abuse or tumors
CT or MRI of pituitary, abdomen and pelvis for tumors
abnormal vaginal bleeding diagnosis and management
1) rule out pregnancy or complications of pregnancy --> incomplete abortion, threatened abortion, ectopic pregnancy, mole
diagnosis --> b-hCG + sonogram

2) rule out anatomic lesions --> vaginal lacerations, cervical polyps, cervicitis, leiomyomas, uterine hyperplasia, adenomyosis
diagnosis --> pelvic exam, saline sonogram, endometrial sampling, hysteroscopy

3) rule out dysfunctional uterine bleeding --> anovulation (hypothyroidism, hyperprolactinemia)
diagnosis --> history of irregular unpredictable menstrual bleeding without cramps; clear thin watery cervical mucus; no midcycle temperature rise; endometrial biopsy shows proliferative endometrium
primary amenorrhea diagnosis
absence of menses at age 14 without 2dary sexual characteristics or
absence of menses at age 16 with secondary sexual characteristics
primary amenorrhea, breasts+, uterus-
Mullerian agenesis --> 46XX, create a vagina
androgen insensitivity --> 46XY but looks female, absent pubic hair, high testosterone; give estrogen, create vagina and remove testes
primary amenorrhea, breasts-, uterus+
gonadal dysgenesis --> Turner, high FSH, no follicles, streak ovaries
HP axis failure --> low FSH, normal ovaries, diagnose with brain scan
Kallman --> +anosmia
secondary amenorrhea diagnosis
absence of menses for 3 months if previously regular
absence of menses for 6 months if previously irregular
first step in evaluation of secondary amenorrhea
b-hCG to rule out pregnancy
etiology of secondary amenorrhea
anovulation --> PCOS, hypothyroidism, pituitary adenoma, hyperprolactinemia, antipsychotics, antidepressants
hypoestrogenic --> absence of functional ovarian folliclles, HP insufficiency
outflow tract obstruction
secondary amenorrhea work-up
1) b-hCG; if negative -->
2) TSH (primary hypothyroidism causes high TRH and hyperprolactinemia); if negative -->
3) prolactin (antipsychotics or pituitary tumor); do MRI tu rule out adenoma; if negative -->
4) progesterone challenge test; if positive then anovulation; if negative then inadequate estrogen -->
5) estrogen-progesterone challenge test;
if positive --> inadequeate estrogen; if high FSH then ovarian failure; if low FSH then HP insufficiency
if negative --> outflow tract obstruction or endometrial scarring; order hysterosalpingogram
idiopathic/constitutional precocious puberty
too much gonadotropins
all puberty changes are seen
6y/o girl
normal MRI

treat with leuprolide to avoid premature closure of epiphysis
McCune-Albright syndrome
autonomous aromatase activation with excess estrogen
complete precocious puberty
6 y/o
café au lait spots
multiple cystic bone lesions

management --> aromatase enzyme inhibitor
granulosa cell tumor
precocious complete puberty
6 y/o girl
pelvic mass

management --> surgery
premenstrual syndrome (PMS) diagnosis
based on diary of symptoms throughout 3 menstrual cycles; must meet all criteria -->

recurrent in at least 3 consecutive cycles
absent in preovulatory phase
present in the 2 postovulatory weeks
intereferes with normal functioning
resolves with onset of menses
premenstrual syndrome management
yaz (drospirenone/estradiol)(low-dose combo OCP, 4-day hormone free)
drospirinon (DRSP)(spironolactone analogue with antimineralocortocoid effects)
SSRIs (for emotional symptoms)
alprazolam (for emotional symptoms)
GnRH agonists
hirsutism due to adrenal tumor
rapid onset virilization
abdominal/flank mass on CT or MRI
markedly elevated DHEAS
remove surgically
hirsutism definition
excessive male-pattern hair growth with or without virilization (clitorimegaly, baldness, deep voice, increased muscle)
hirsutism due to Sertoli-Leydig tumor
rapid onset virilization
adnexal pelvic mass on exam and ultrasound
markedly elevated testosterone
remove surgically
hirsutism due to congenital adrenal hyperplasia
21-hydroxylase deficiency
gradual onset hirsutism without virilization
normal exam
markedly increased 17OH progesterone
treat with corticosteroid replacement
hirsutism work-up
sudden onset --> testosterone and DHEAS levels, pelvic exam, abdominal CT or MRI, pelvic ultrasound
gradual onset --> serum 17OH progesterone levels, testosterone, pelvic ultrasound (PCOS)
differential diagnosis of hirsutism
21-hydroxylase deficiency
stromal ovarian tumor
PCOS
idiopathic (MCC)
adrenal tumor
idiopathic hirsutism
due to 5-alpha reductase overactivity
gradual onset hirsutism
normal DHEAS, 17-OH progesterone and testosterone
treat with spironolactone or eflornithine
polycystic ovarian syndrome presentation
irregular menstrual bleeding (from anovulation/unopposed estrogen; gonadotropins arent pulsatile)
hirsutism (increased LH stimulates androgens which also decrease SHBG)
obesity
infertility
ovarian enlargement with multiple cysts
polycystic ovarian syndrome diagnosis
suspected with --> irregular menstrual bleeding, obesity, hirsutism, infertility
confirmed with --> LH/FSH ratio 3:1 (normal is 1.5:1)
polycystic ovarian syndrome management
OCPs (normalize bleeding and suppress LH)
spironolactone (suppresses 5-alpha reductase)
if pregnancy is desired --> clomiphene
semen analysis for infertility
normal values:
volume >2ml
pH 7.2-7.8
sperm density >20million/ml
motility >50%
morphology >50% normal

if sperm density is low --> intrauterine insemination
if severely abnormal --> intracytoplasmic sperm injection or in-vitro fertilization
causes of infertility
primary hypothyroidism
hyperprolactinemia
PCOS
pituitary adenoma
antipsychotics
PH insufficiency
ovarian insufficiency
semen abnormalities
PID
infertility work-up
1) initial step is semen analysis
2) rule out anovulation with history, progesterone levels, endometrial biopsy and temperature chart
3) if semen is normal and anovulation is ruled out --> hysterosalpingogram
if positive --> attempt laparoscopic correction OR in-vitro fertilization
if negative --> unexplained infertility; spontaneous pregnancy occurs in 60% at 3 years OR treat with clomiphene+intrauterine insemination
premature ovarian failure
hot flashes and sweats
>30 y/o
high FSH
menopause presentation and diagnosis
presentation --> amenorrhea, hot flashes, cardiovascular disease, osteoporosis
diagnosis --> 3 months of amenorrhea with elevation of gonadotropins
osteoporosis presentation and diagnosis
vertebral crush fractures, hip and wrist fractures
diagnosis --> dual-energy x-ray absoprtiometry (DEXA scan)
osteoporosis management
lifestyle changes --> Ca+ and vitamin D, weight-bearing exercise, stop cigarettes and alcohol
medications --> biphosphonates and/or SERMs (raloxifene)
risks of hormone replacement therapy
estrogen+progestin --> breast cancer, heart disease, stroke
estrogen alone --> risk of stroke; no change in risk of breast cancer or heart disease
both groups --> DVT
benefits of hormone replacement therapy
improves -->

vaginal dryness
hot flashes
vasomotor symptoms
osteoporois
indications of hormone replacement therapy
only indication is vasomotor symptoms
if only need to treat osteoporosis consider SERMs
cystic breast mass diagnosis and management
diagnosis --> cyst aspiration and fine-needle aspiration with pathology exam
management --> preaspiration mammography then aspiration; if benign, no further work-up
fibrocystic breast change presentation
bilateral breast enlargement which fluctuates with menstrual periods (cyclic mentrual mastalgia)
may have palpable painful nodules
fibrocystic breast change diagnosis and management
aspiration and complete drainage
mass dissapears and fluid is clear --> discard fluid; reexamine in 4-6 weeks
mass dissapears and fluid is bloody --> send for cytologic exam; reexamine in 4-6 weeks
mass persists after aspiration --> wait 2 weeks after aspiration then mammography + excisional biopsy
fibroadenoma presentation
most common in adolescents and young women
discrete, smoothly contoured, rubbery, nontender, movable mass
fibroadenoma diagnosis and management
diagnose with ultrasound or fine needle aspiration showing a solid mass that does not collapse after aspiration
treat conservatively or elective excisional biopsy
mammographic calcifications
nonpalpable; most are benign but 15-20% are early cancer; requires steoretactic needle localization and biopsy under mammographic guidance; treatment depends on histology
indications of excisional biopsy of the breast
cellular bloody cyst on fluid aspiration
failure of a suspicious mass to dissapear completely upon aspiration
bloody nipple discharge with or without palpable mass
skin edema and erythema and needle biopsy cannot be performed
bloody nipple discharge
requires excisional needle biopsy
usually results from intraductal papilloma
management based on histology
breast cancer management
determine prognostic factors
stages I and II do breast-conserving therapy with wide excision + axillary node dissection or sentinel node biopsy + radiotherapy
breast cancer prognostic factors
lymph node status --> most important; inversely proportional to survival
tumor size --> correlates with lymph node involvment but 15% of small tumors have positive node involvement
receptor status --> estrogen and progesterone receptor status is needed before surgical therapy; it's prognostic and predictive factor
DNA ploidy --> determines diploid or aneuploidy (worse); it's unclear wether this is an independent risk factor
infiltrating ductal carcinoma
80% of breast cancers
starts as atypical ductal hyperplasia --> ductal carcinoma in situ --> invasive
mas is stony hard and increases in size
infiltrating lobular carcinoma
10% of breast cancers
better prognosis than infiltrating ductal carcinoma
inflammatory breast cancer
uncommon
rapid growth with early metastasis
skin is erythematous, swollen, warm, edematous and orange
paget disease
uncommon
lesion is pruritic, red and scaly, located in nipple and areola
nipple may become inverted
discharge may occur
breast cancer risk factors
BRCA 1 or 2 gene mutation (RR 15)
ductal or lobular carcinoma in situ (RR 15)
atypical hyperplasia (RR 4)
breast irradiation age < 20 (RR 3)
positive family history (RR 3)
sentinel node biopsy
first lymph node to which cancer cells are likely to spread from primary tumor
dye is injected into tumor which flows into the sentinel node
biopsy is performed to determine stage and if removal of nodes is necessary
adjuvant treatment for node positive breast cancer
premenopausal, ER or PR positive --> chemo +- ovarian ablation +- tamoxifen
premnopausal, ER and PR negative --> chemo
postmenopausal, ER or PR positive --> tamoxifen + chemo
postmnopausal, ER and PR negative --> chemo
elderly --> tamoxifen or chemo
diagnosis of pregnancy
presumptive --> amenorrhea, breast tenderness, nausea, vomiting, hyperpigmentation, skin striae
probable --> increased uterine size, postitive beta-hCG
positive --> hearing fetal heart tones, sonographic visualization of fetus, perception of fetal movements
pregnancy dating
conceptual dating --> 266 days or 38 weeks
menstrual dating assuming 28 day cycle --> 280 days or 40 weeks
calculate due date --> LMP - 3 months + 7 days +- 1 week
first trimester events and complications
from conception to 13 menstrual weeks
nausea, vomiting, breast tenderness, frequent urination
spotting and bleeding in 20% (50% of which will continue normally)
average weght gain is 5-8 pounds
complications --> spontaneous abortion
second trimester events and complications
from 13-26 menstrual weeks
round ligament pain
Braxton-Hicks contractions are painless
quickening (maternal awareness of fetal movements) starting at 16 weeks
average weight gain is 1 pound/week after 20 weeks
complications --> incompetent cervix, premature membrane rupture, premature labor
third trimester events and complications
26-40 menstrual weeks
lower back and leg pain
urinary frequency
Braxton-Hicks contractions
lightening
bloody show
average weight gain is 1 pound/week after 20 weeks
complications --> premature membrane rupture, premature labor, preeclampsia, urinary tract infection, anemia, gestational diabetes
1st trimester lab tests: CBC
normal hemoglobin --> 10-12g/dL due to dilutional effect
MCV --> low hemoglobin and MCV (<80) suggests iron defficiency; low hemoglobin and high MCV (>100) suggests folate defficiency
thrombocytopenia --> idiopathic thrombocytopenic purpura or pregnancy induced thrombocytopenia
leukocytosis up to 16,000/mm3 is normal; leukopenia suggests immune suppression or leukemia
1st trimester lab tests: rubella IgG
absence of antibodies has fetal risks; vaccine is contraindicated in pregnancy but recommended after delivery
1st trimester lab tests: hepatitis B
HbsAb --> successful vaccination
HbsAg --> previous or present infection; only routine hepatitis test on prenatal lab panel
HbeAg --> highly infectious state
1st trimester lab tests: type, Rh and antibody screen
blood type and Rh --> direct Coombs test; if Rh negative risk for anti-D isoimmunization
1st trimester lab tests: STDs
cervical cultures --> chlamydia and gonorrhea
syphilis --> VDRL; if positive --> MHA-TP or FTA-ABS
hepatitis B --> HbsAg
HIV (requires consent) --> screen with ELISA; if positive --> western blot
1st trimester lab tests: urine
urinalysis --> suggests renal disease, diabetes, infection
urine culture --> to screen for asymptomatic bacteriuria (8% of pregnant women)
1st trimester lab tests: TB
PPD --> done in high-risk populations, not routinely
if positive PPD --> chest x-ray
if chest x-ray negative --> INH + B6 9 months
if chest x-ray positive --> sputum culture and triple therapy until cultures return
1st trimester lab tests: cervical pap smear
to identify cervical dysplasia or malignancy
routine 1st trimester lab tests
complete CBC
rubella IgG
cervical culture (chlamydia, gonorrhea)
HbsAg
VDRL
HIV
urinalysis
urine culture
cervical pap smear
2nd trimester lab tests: MS-AFP
elective prenatal test; (only 20% sensitivity for trisomy 21)
detects neural tube defects, ventral wall defects, twin pregnancy, placental bleeding, fetal renal disease, teratoma
if >2.5 MoM --> ultrasound to confirm gestational age
if error --> re-do MS-AFP
if correct --> amniocentesis for AF-AFP and AF acetylcholinesterase (NTD)
if <0.85 MoM --> ultrasound to confirm gestational age
if error --> re-do MS-AFP
if correct --> amniocentesis for karyotype (trisomy 21)
triple marker screen
window is 15-20 weeks
MS-AFP, hCG and estriol
trisomy 21 --> low MS-AFP and estriol with high hCG; perform amniocentesis for karyotype
trisomy 18 --> all markers are decreased; perform amniocentesis for karyotype
quadruple marker screen --> inhibin A; increases sensitivity for Down to 80%
gestational diabetes testing
1-h 50g oral glucose tolerance test --> screening test to all pregnant women between 24-28weeks
if >140mg/dL at 1 hour --> 3-h 100g oral glucose tolerance confirmatory test after overnight fast
if fasting blood glucose >125mg/dL --> diabetes mellitus; no further testing required
else --> FBS: <95mg/dL 1h: <180mg/dL 2h: <155mg/dL 3h: <140mg/dL
if one abnormal value --> impaired glucose tolerance
if two abnormal values --> gestational diabetes
third trimester lab tests: CBC
should be performed between 24-28weeks in all pregnancies checking for iron defficiency anemia and pregnancy induced thrombocytopenia
third trimester lab tests: atypical antibody screen
indirect Coombs test at 28 weeks for all Rh negative women
if no isoimmunization (no anti-D antibodies) --> RhoGAM
else --> RhoGAM is futile
third trimester lab tests
1h oral glucose tolerance test between 24-28weeks
CBC
atypical antibody screen + RhoGAM
late pregnancy bleeding differential diagnosis
cervical causes --> erosion, polyps, carcinoma
vaginal causes --> varicosities, lacerations
placental causes --> abruptio placenta, placenta previa, vasa previa
late pregnancy bleeding work-up
CBC
DIC work-up (platelets, PT, PTT, fibrinogen, D-dimer)
type and cross-match
sonogram for placental location
never perform digital or speculum exam until sonogram rules out placenta previa
abruptio placenta presentation
late trimester painful bleeding (external or retroplacental hematoma)
normal placental implantation
DIC
abruptio placenta diagnosis
painful late trimester bleeding with a normal fundal or lateral wall placental implantation (upper 2/3 uterus)
abruptio placenta risk factors
previous abruption
hypertension
maternal trauma
cocaine
premature membrane rupture
abruptio placenta management
if maternal or fetal jeopardy --> emergency cesarean
if bleeding is controlled and >36 weeks --> induce vaginal delivery with amniotomy
if mother and fetus are stable and remote from from term with subsiding signs --> conservative in-hospital observation
abruptio placenta complications
hemorrahgic shock with acute tubular necrosis and DIC
placenta previa presentation and diagnosis
late trimester painless bleeding
ultrasound shows placental implantation over the lower segment
placenta previa risk factors
previous placenta previa
multiple gestation
multiparity
advanced maternal age
placenta previa management
if maternal or fetal jeopardy --> emergency cesarean delivery
if mother and fetus are stable --> conservative in-hospital observation with blood transfusions
if placental edge >2cm from internal cervical os --> vaginal delivery
if 36weeks and lung maturity confirmed by amniocentesis --> scheduled cesarean delivery
placenta previa complications
if placenta is implanted over previous uterine scar --> intractable bleeding requiring cesarean hysterectomy
if too much blood loss and hypotension ---> Sheehan or acute tubular necrosis
placenta accreta/increta/percreta
accreta (MC) --> villi invade deeper layers of endometrium but not myometrium
increta --> villi invade the myometrium but not serosa or bladder
percreta --> villi invade the serosa or bladder
vasa previa
presentation --> rupture of membranes, painless vaginal bleeding and fetal bradycardia
diagnosis --> suspected when sonogram has previously revealed a vessel crossing the membranes over internal cervical os
risk factors --> velamentous insertion of umbilical cord, accessory placental lobes, multiple gestation
management --> immediate cesarean
uterine rupture
presentation --> vaginal bleeding, loss of electronic fetal heart rate signal, abdominal pain, loss of station of fetal head
diagnosis --> surgical exploration of the uterus to identify the tear
risk factors --> classic (vertical) uterine incision, myomectomy, excessive oxytocin stimulation
management --> surgical immediate delivery with uterine repair or hysterectomy
GBS neonatal sepsis
presentation --> newborn sepsis within hours of birth with bilateral pneumonia (50%) mortality
prevention --> IV penicillin G if -->
positive GBS urine culture or previous baby with GBS sepsis
positive vaginal culture at 36-37weeks
risk factors: preterm gestation, membranes ruptured>18h, maternal fever
congenital toxoplasmosis
can only occur during the parasitemia of a primary infection
40% of pregnant women are toxoplasmosis IgG seropositive
fetal infection --> IUGR, fetal hydrops, microcephaly, itracranial calcifications
neonatal findings --> chorioretinitis, seizures, hepatosplenomegaly
prevention --> avoid infected cat feces, raw goat milk, undercooked meat
varicella infection
neonatal findings --> zigzag skin lesions, micropthalmia, chorioretinitis, extremity hypoplasia
prevention --> varicella zoster immune globulin within 96h of exposure or live-attenuated vacciine to non-pregnant with no IgG
treatment --> acyclovir if maternal varicella pneumonia, encephalitis or immunocompromised
congenital rubella
presentation --> congenital deafness, congenital cataracts, congenital heart disease
prevention --> all pregnant women should be screened for ruberlla IgG; if negative then vaccination after delivery
cytomegalovirus infection
fetal manifestations --> hydrops, IUGR, microcephaly, periventricular cerebral calcifications
neonatal findings --> sensorineural deafness; if symptomatic: petechiae, meningoencephalitis, jaundice
treatment --> ganciclovir
HIV in pregnancy
triple therapy recommended including ZDV
cesarean should be offered at 38 weeks
breast feeding should be avoided
syphilis
fetal --> hydrops, macerated skin, anemia, thrombocytopenia, hepatosplenomegaly
neonatal ---> Hutchinson teeth, mullberry molars, saber shins, saddle nose, VIII nerve deafness
obstetric complications
cervical insufficiency
multiple gestations
isoimmunization
preterm labor
premature rupture of membranes
postterm pregnancy
hypertensive complications
gestational hypertension
mild preeclampsia
severe preeclampsia
eclampsia
chronic hypertension
HELLP syndrome
medical complications in pregnancy
cardiac disease
thyroid disease
epilepsy
diabetes
anemia
liver disease
UTIs
thrombophilias
thromboembolism
cervical insufficiency
painless cervical dilation at 18-22 weeks with possible delivery of previable baby
diagnosis --> ultrasound
management --> elective cerclage or emergency cerclage if theres sonographic evidence and after ruling out labor and chorioamnionitis
multiple gestations
Di-Di twins --> 2 zygotes; two placentas seen
mono-di twins --> one zygote; one placenta, two sacs
mono-mono twins --> one zygote; one placenta, one sac
presentation --> hyperemesis gravidarum due to high beta-hCG, uterus larger than dates, high AFP
diagnosis --> more than one fetus on sonogram
management --> iron and folate, monitor blood pressure, vaginal delivery if both cephalic, else cesarean
determination of fetal risk in isoimmunization
present if:
atypical antibodies detected with indirect Coombs test
antibodies are associated with hemolytic disease of newborn
titer more than 1:8
father of baby is antigen positive

else --> no risk

if ATT <1:8 management is conservative; repeat titer monthly
determine degree of fetal anemia in isoimmunization
amniocentesis bilirubin --> indirectly indicates fetal hemolysis; plotted on Liley graph; severe anemia if zone III
PUBS --> directly measures fetal hematocrit; severe anemia if <25%
ultrasound doppler -->measures peak flow velocity of fetal blood through middle cerebral artery; higher velocity, more anemia
criteria for intervention in isoimmunization
severe fetal anemia is diagnosed when Liley Is in zone 3 or PUBS shows fetal hematocrit <25%

perform intrauterine intravascular transfusion if <34 weeks
delivery if >34 weeks
management of isoimmunization
1) determine fetal risk
2) determine degree of anemia
3) intervene if severe anemia
prevention of isoimmunization
RhoGAM routinely:
1) to Rh negative mothers at 28 weeks
2) within 72h of chorionic villus sampling, amniocentesis or D&C
3) within 72h of delivery of an Rh positive infant
preterm labor diagnosis
pregnancy 20-36 weeks
>= 3 contractions in 30 min
cervix >=2cm or changing

all three should be positive for diagnosis
preterm labor presentation
lower abdominal pain or pressure
lower back pain
increased vaginal discharge
bloody show
preterm contractions
pregnancy 20-36 weeks
>=3 contractions in 30 minutes
dilated <2cm and no change
tocolytic contraindications
obstetric --> abruptio placenta, ruptured membranes, chorioamnionitis
fetal --> lethal anomaly, fetal demise
maternal --> eclampsia, severe preeclampsia, advanced cervical dilation
tocolytic agents
may prolong pregnancy but for no more than 72h to administrate maternal IM betamethasone for lung maturation and transport mother to a facility with neonatal intesive care

magnesium sulfate
terbutaline
nifedipine
indomethacin
magnesium sulfate for tocolysis
competitive inhibitor of calcium
side effects --> muscle weakness, respiratory depression, pulmonary edema
contraindications --> renal insufficiency and myasthenia gravis
treat overdose with IV calcium gluconate
terbutaline for tocolysis
depends on myometrial beta2 receptor activity
side effects --> hypertension, tachycardia, hyperglycemia, hypokalemia
contraindications --> cardiac disease, diabetes, uncontrolled hyperthyroidism
calcium channel blockers for tocolysis
side effects --> tachycardia, hypotension, myocardial depression
contraindications --> hypotension
indomethacin for tocolysis
decreases prostaglandin production
side effects --> oligohydramnios, PDA closure in utero
contraindications --> gestational age >32 weeks
preterm labor management
confirm labor with specific criteria
rule out contraindications for tocolysis
IV hydration with IV fluids
magnesium sulfate 5g IV for 20 minutes then 2g/h
cervical and urine cultures for GBS prophylaxis
maternal IM betamethasone if <34 weeks
preterm labor prevention
women with history of previous preterm delivery should receive IM 17alpha-OH progesterone starting at 20 weeks
premature rupture of membranes presentation
sudden gush of copious vaginal fluid
clear fluid flowing out of vagina
oligohydramnios seen in ultrasound
premature rupture of membranes diagnosis
sterile speculum exam showing:
1) posterior fornix pooling of amniotic fluid
2) nitrazine positive fluid turns pH-sensitive paper blue
3) fern positive pattern when fluid is allowed to dry on glass slide
chorioamnionitis diagnosis
need all criteria:
maternal fever and uterine tenderness
in the presence of PROM
in the absence of a URI or UTI
PROM management
if uterine contractions are present --> tocolysis is contraindicated
if chorioamnionitis is present --> cervical cultures, IV antibiotics and prompt delivery
if infection is absent and <24 weeks --> induce labor or manage with bed rest
if 24-33 weeks --> bed rest, IM betamethasone, cervical cultures, 7-day prophylactic ampicillin+erythromycin
if >34 weeks --> initiate prompt delivery with oxytocin or prostaglandins or cesarean
postterm pregnancy
>40 weeks from conception or >42 mentrual weeks
can predispose to macrosomia (viable placenta) or dysmaturity syndrome (decaying placenta)
if sure date and favorable cervix --> induce labor with oxytocin and artificial rupture of membranes
else --> conservative
gestational hypertension
pregnancy >20weeks
nonsustained BP >140/90 without proteinuria
conservative management and preeclampsia should ruled out
mild preeclampsia
pregnancy >20weeks
sustained hypertension >140/90 with proteinuria 1-2+ or >300mg on 24h urine
hemoconcentration
if stable and <36w --> conservative management and no antihypertensive or MgSO4
if >36w --> induce labor with dilute oxytocin and IV MgSO4 to prevent eclamptic seizures
severe preeclampsia
preganancy >20weeks
sustained hypertension >160/110 + >300mg proteinuria
sustained hypertension >140/90 + 3-4+ or >5g proteinuria
sustained hypertension >140/90 with headache, epigastric pain, visual changes, DIC, elevated liver enzymes or pulmonary edema
if maternal or fetal jeopardy --> IV MgSO4, hydralazine/labetalol and prompt delivery
if no maternal or fetal jeopardy and 26-34 weeks --> conservative if BP can be lowered, IV MgSO4 and IM betamethasone
eclampsia
unexplained grand mal tonic clonic seizures + hypertension + proteinuria
first step in management --> protect mother's airway and tongue
MgSO4
aggressive prompt delivery
lower diastolic BP with IV hydralazine or labetalol
chronic hypertension
BP >140/90 with onset before 20 weeks
superimposed preeclampsia --> worsening BP, worsening proteinuria or maternal jeopardy
antihypertensive drugs in pregnancy
if mild to moderate HTN --> may discontinue medications if theres normal decrease in BP
if severe hypertension --> methyldopa
ACEIs and diuretics are contraindicated in pregnancy
BP target is diastolic between 90-100
chronic hypertension management
if uncomplicated --> conservative; discontinuation of antihypertensives, serial sonograms, serial BP and urinalysis
if superimposed preeclampsia --> MgSO4, hydralazine/labetalol and prompt delivery
HELLP syndrome
complication of preeclampsia
hemolysis + elevated liver enzymes + thrombocytopenia
manage with prompt delivery
antepartum maternal overt diabetes measures
Hemoglobin A1c on first visit and each trimester
early pregancy baseline 24h urine protein to assess renal status
assess retinal status with fundoscopy
home blood glucose monitoring
antepartum fetal assesment in overt diabetes
triple marker screen at 16-18 weeks for NTDs
targetted ultrasound at 18-20 weeks
if glycosylated hemoglobin is high --> fetal echo at 22-24 weeks
monthly sonogram for macrosomy or IUGR
no increased risk of anomalies in gestational DM because anomalies are in first trimester
intrapartum management of overt DM
lung maturity is often delayed
target delivery date is 40 weeks
amniocentesis for lecithin/sphingomyelin ration of 2.5 in the presence of phosphatidyl glycerol assures lung maturity
cesarean is considered if macrosomia
postpartum management of overt DM
watch for uterine atony related to overdistended uterus which causes postpartum hemorrhage
falling levels of hPL decreases insulin resistance so turn off insulin infussion
neonatal complications of overt DM
hypoglycemia due to hyperinsulinism
hypocalcemia due to failure of parathyroids
polycythemia due to high erythropoietin from relative hypoxia
hyperbilirubinemia
respiratory distress syndrome due to low surfactant
iron deficiency anemia
general malaise, palpitations, andkle edema
hemoglobin <10g, MCV <80, RDW >15%
FeSO4 325mg po tid
prevent with elemental iron 30mg/day
folate deficiency anemia
malaise, palpitations, ankle edema
hemoglobin <10g, MCV >100, RDW >15%
fetal effects --> low birth-weight, NTDs
treatment --> folate 1mg po/day
prevent --> folate 0.4mg po/day; 4mg if risk of NTDs
sickle cell anemia
screening --> peripheral test to detect hemoglobin S
final diagnosis --> hemoglobin electrophoresis to differentiate between SA trait and SS disease
complications --> spontaneous abortions, IUGR, fetal deaths, preterm delivery
treatment --> avoid hypoxia, folate supplements, monitor fetal well being
intrahepatic cholestasis of pregnancy
intractable pruritus on the palms and soles, worst at night, without rash
diagnosis --> markedly increased serum bile acids, mild bilirubin elevation
treatment --> gold standard is ursodeoxycholic acid; may also use cholestyramine and antihistamines in mild cases
acute fatty liver
nonspecific --> nausea, vomit, anorexia, epigastric pain
hypertension, proteinuria, edema can mimic preeclampsia but hypoglycemia and high serum ammonia are specific
can also have acute renal failure, pancreatitis, hepatic encephalopathy, coma
moderate elevation of liver enzymes, hyperbilirubinemia and DIC
prompt delivery is indicated
asymptomatic bacteriuria
no urgency, frequency or burning
no fever
positive urine culture with >100K CFU
single antibiotic treatment
acute cystitis
urgency, frequency, burning
no fever
positive urine culture with >100K CFU
antibiotic monotherapy
acute pyelonephritis
urgency, frequency, burning
systemic signs --> fever with chills, anorexia, nausea, vomit, flank pain
positive urine culture with >100K CFU
hospital admission, hydration, IV antibiotics and tocolysis if needed
thrombophilia etiology and pregnancy complications
factor V Leiden
prothrombin mutations
hyperhomocysteinemia
antithrombin III deficiency
protein C/S deficiency
antiphospholipid syndrome

complications --> first trimester miscarriages, stillbirths, placental abruption, preeclampsia, pulmonary embolus (MC COD in pregnant women)
thrombophilia diagnosis
all pregnant women with blood clot should be tested for:
factor V Leiden and prothrombin gene mutations
hyperhomocysteinemia
antithrombin III, protein C, protein S deficiency
antiphospholipid syndrome

recommended testing if:
familiy history of thrombosis, pulmonary embolism, thrombophilias or pregnancy complications
thrombophilia treatment
subcutaneous heparin +- aspirin
low-molecular weight is better than unfractionated
monitor blood levels for anticoagulation effect
warfarin postpartum 6-8 weeks
superficial thrombophlebitis
localized pain and sensitivity, erythema, tenderness, swelling
diagnosis of exclusion after ruling out DVT with doppler or venography
manage with bed rest, local heat and NSAIDs
deep venous thrombosis
pain and increased skin sensitivity, calf pain
diagnosis --> duplex Doppler (above knee) or venography (below knee); perform thrombophilia work-up
treatment --> IV heparin
pulmonary embolus
chest pain, dyspnea, tachypnea, normal x-ray, low pO2 on ABG, tachycardia
diagnosis --> initially spiral CT
if CT negative and high risk symptomatic patient --> pulmonary angiography
perform thrombophilia work-up
management --> IV heparin
IUGR definition and etiology
estimated fetal weight <5-10th percentile for gestational age
or birth weight <2,500grams
fetal causes --> aneuploidy, TORCH, structural anomalies --> symmetrical
placental causes --> infarction, abruption, twin-twin transfusion --> asymmetric
maternal causes --> hypertension, small vessel disease, malnutrition, tobacco, alcohol, drugs
symmetrical IUGR
all ultrasound parameters are smaller than expected
workup --> detailed sonogram, karyotype, screen for fetal infections
asymmetrical IUGR
head sparing but abdomen small
serial sonograms, non-stress tests, amniotic fluid index (decreased), biophysical profile, umbilical artery Doppler
macrosomia definition and risk factors
estimated fetal weight >90-95th percentile for gestational age
or birth weight >4,000-4,500 grams

risk factors --> gestational or overt diabetes, prolonged gestation, obesity, weight gain
macrosomia complications and management
maternal --> operative vaginal delivery, perineal lacerations, postpartum hemorrhage, emergency C-section
fetal --> shoulder dystocia, birth injury, asphyxia
neonatal --> intensive care admission, hypoglycemia, Erb palsy

manage with C-section
nonstress tests
reactive NST:
>=2 accelerations in 20 min; >10 or 15 beats/min for >10 or 15 seconds
interpretation --> reassuring of fetal well-being
repeat weekly or biweekly

non-reactive NST:
no accelerations or did not meet criteria
interpretation --> sleeping fetus, immature, sedated
perform vibroacoustic stimulation test
if still not reactive --> biophysical profile
amniotic fluid index
<5cm --> oligohydramnios
5-8cm --> borderline
9-25cm --> normal
>25cm --> polyhydramnios
biophysical profile
NST, amniotic fluid volume, fetal gross body movements, fetal extremity tone and fetal breathing movements

8-10 --> highly reassuring; repeat weekly or as indicated
4-6 --> worriesome; delivery if >36weeks or repeat in 12-24 hours
0-2 --> fetal hypoxia; prompt delivery regardless of age
contraction stress test
negative CST:
no late decelerations in the presence of 3 contractions in 10min
reassuring of fetal well being
repeat CST weekly

positive CST:
repetitive late decelerations in the presence of 3 contractions in 10min
worriesome, especially in nonreactive NST
prompt delivery
contraction stress test indications and contraindications
indication --> BPP 4-6

contraindications --> should not stimulate contractions if:
previous classical uterine incision
previous myomectomy
placenta previa
incompetent cervix
preterm membrane rupture
preterm labor
umbilical artery Doppler
absent or reversed diastolic flow is predicitive of poor perinatal outcome only in IUGR fetuses
types of pelvis
gynecoid, android, anthropoid, platypelloid
fetal lie
longitudinal --> fetus and mother in same vertical axis
transverse --> fetus at right angles to mother
oblique --> fetus at 45 degree angle to mother
fetal presentation
cephalic --> head first; most common
frank breech --> thighs flexed, legs extended
complete breech --> thighs and legs are flexed
footling breech --> thighs and legs are extended
compound --> more than one anatomic part is presenting
shoulder --> shoulder first
fetal position
occiput anterior or posterior --> flexed head on cephalic presentation
sacrum anterior or posterior --> breech presentation
mentum anterior or posterior --> extended head on face presentation
definition of labor
effacement and dilation of the cervix with uterine contractions at least every 5min lasting 30s; resulting in delivery of fetus and expulsion of placenta
physiology of labor
increasing frequency of contractions
formation of gap junctions between uterine myometrial cells
increasing levels of oxytocin and prostaglandins
multiplications of specific receptors
upper uterine segment --> contractile, mostly smooth muscle, thickens
lower uterine segment --> passively thins out, mostly collagen fibers
cervical effacement and dilation
0% effacement --> cervix is 2cmX2cm; oxytocin and prostaglandins break dissulfide likanges of collagen fibers
dilation --> complete dilation is 10cm as lower uterus is thinned and pulled up by upper uterus
movements of labor
1) engagement --> presenting part moves below pelvic inlet
2) descent --> presenting part moves through curve of birth canal
3) flexion --> fetal chin on thorax
4) internal rotation --> fetal head from transverse to antero-posterior in mid pelvis
5) extension --> fetal chin moves away from thorax
6) external rotation --> fetal head rotates after passing pelvic outlet
7) expulsion --> delivery of fetal shoulders and body
stages of labor
stage 1 latent phase --> regular uterine contractions-acceleration of cervical dilation; <14-20 hours
stage 1 active phase --> acceleration-10cm dilation; >1.2-1.5cm/hour
stage 2 descent --> 10cm dilation-delivery; 1-2 hours
stage 3 expulsion --> delivery of baby-delivery of placenta; <30min
stage 4 --> 2h observation period
management of labor
preadmission --> not admitted until cervical dilation is 3cm unless ROM; presentation is confirmed
admission --> IV access
first stage --> assess fetal heart rate and perform serial vaginal exams checking dilation and descent
stages 2 and 3 --> pushing efforts; episiotomy might be performed; IV oxytocin after delivery of placenta
prolonged latent phase
pregnant with regular uterine contractions
cervix dilated 2cm
no cervical change in 14 or 20 hours

management --> rest and sedation
prolonged active phase
pregnant with regular uterine contractions
cervix dilated >3cm
cervical dilation <1.2 or 1.5cm

management:
normal contractions --> 2-3min, 45-60sesc, 50mmHg
if hypotonic --> IV oxytocin
if hypertonic --> morphine
if adequate --> emergency cesarean
active phase arrest
pregnant with regular uterine contractions
cervix dilated >3cm
cervical dilation not changed for >2h

management:
normal contractions --> 2-3min, 45-60sesc, 50mmHg
if hypotonic --> IV oxytocin
if hypertonic --> morphine
if adequate --> emergency cesarean
stage 2 arrest
pregnant with regular uterine contractions
10cm dilation at +1 station
no descent change in 3h

management:
IV oxytocin enhanced coaching
if adequate and head not engaged --> emergency cesarean
if adequate and head engaged --> obstetric forceps or vacuum extractor
prolonged third stage
failure to deliver plaenta within 30 minutes in spite of oxytocin
suspect placenta acreta, increta or percreta
may require manual placental removal or hysterectomy
prolapsed umbilical cord
pregnnt with regular uterine contractions
amniotomy at -2 station
severe variable decelerations

management --> don't hold the cord or push back into uterus; place patient in knee-chest position; elevate presenting part and perform immediate cesarean delivery
shoulder dystocia
second stage of labor
head has delivered
no further delivery of body

management --> suprapubic pressure; maternal thigh flexion; internal rotation of fetal shoulder
obstetric lacerations
first degree --> vaginal mucosa
second degree --> vagina and muscles of perineal body
third degreee --> vagina, perineal muscles, anal sphincter
fourth degree --> vagina, perineal muscles, anal sphincter and rectal mucosa
obstetric anesthesia physiology
stage 1 --> T10-T12
stage 2 --> S2-S4
pregnancy predisposes to hypoxia
medications can pass the placenta to fetus
give antacids prophylactically
uterus should be laterally displaced
IV anesthetics
narcotics and sedatives
active phase
neonate may need naloxone antidote
paracervical block
bilateral transvaginal injection to block Frankenhauser ganglion
active phase
transitory fetal bradycardia
pudendal block
bilteral transvaginal injection to block pudendal nerve at ischial spine
stage 2
epidural block
injection into epidural space to block lumbosacral roots
stages 1 and 2
side effects --> hypotension (treat with IV fluids and ephedrine); spinal headache
spinal block
injection into subarachnoid space to block lumbosacral roots
stage 2
side effects --> hypotension
types of decelerations
early --> with contractions
variable --> before or with contractions
late --> after contractions (non reassuring)
reassuring FHR tracings
baseline rate 110-160/min
accelerations
no decelerations
variability is present
nonreassuring FHR tracings
baseline rate is tachycardia or bradycardia
accelerations absent
repetitive variable decelerations
repetitive late decelerations
variability is absent
intrauterine resuscitation
decrease uterine contractions --> turn off oxytocin or administer 0.25 terbutaline
500mL bolus of normal saline
8-10L O2 by facemask
amniofusion
lateral position
vaginal exam to rule out prolapsed umbilical cord
scalp stimulation
fetal pH assessment
normal fetal pH is 7.2 or more
fetal scalp blood pH
postpartum umbilical arter blood pH
management of nonreassuring fetal monitoring tracings
intrauterine resuscitation
if no normalization --> prompt delivery
forceps or vaccum extractor indications
prolonged second stage (MC indication)
nonreassuring FHM tracings
to avoid maternal pushing
breech presentation
indications for cesarean
cephalopelvic disproportion
nonreassuring tracings
presentations other than cephalic
uterine atony
risks --> rapid labor, chorioamnionitis, MgSO4, halothane, overdistended uterus
soft uterus palpable over the umbilicus
treat with uterine massage and oxytocin, methylergonovine or carboprost
lacerations
risks --> uncontrolled vaginal delivery, operative vaginal delivery
identifiable lacerations in the presence of a contracted uterus
treat with surgical repair
retained placenta
missing placental cotyledons in the presence of contracted uterus
treat with manual removal or uterine curetagge by sonogram
uterine inversion
bleeding mass in the vagina and failure to palpate uterus
treat by lifting uterus back to its position and giving oxytocin