Ob-Gyn CaseFiles

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parity

number of pregnancies that have ended at gest ages greater than 20 wks

abortuses

number of pregnancies that have ended at gest ages less than 20wks

vulvar mass at 5:00 or 7:00 positions can sugests

Bartholin gland cyst or abscess

pigmented lesions in vulvar region may suggest

malignant melanoma

nodularity and tenderness in the uterosacral ligament can suggest

endometriosis

Rh neg women get Rhogam when

28 wks gest, and at delivery

positive RPR or BDRL test. next step

confirmation with a treponemal test, such as MHATP (microhemagglutination assay for antibodies to treponema pallidum) or FTA-ABS (fluorescent treponema antibody absorbed)

positive for HIV by ELISA. next step

Western blot to confirm

screen for gest diabetes when

at 26 to 18 wks; 50g oral glucose lead, assesment of serum glucose after 1 hr

threatened abortion. next step labs

quantitative hCG and/or progesterone

menorrhagia due to uterine fibroids. next step labs

CBC, endometrial biopsy (for endometrial cancer), Pap smear (for cervical dysplasia or cancer)

woman55 yr or older with an adnexal mass. next step labs

CA-125 and CEA tumor markers for epithelial ovarian tumors

thickened endometrial strip in postmenopausal woman may indicate; fluid in cul-de-sac may indicate

malignancy; ascites (corr w malig)

sonohysterography

us exam of uterus, inject saline into endometrial cavity. can identify endometrial polyps or submucous myomata (tumor composed of mm tiss)

why MRI

IDs soft tissue planes and can help define mullerian defects, such as vaginal agenesis or uterine didelphys. maybe helpful in establishing the location of a pregnancy

why intravenous pyelogram (IVP)

asses concentrating ability of the kidneys, patency of the ureters, integrity of the bladder

why hysterosalpingogram (HSG)

this uses dye, injected thru cervix, and radiographs are taken. usedful for the detection of intrauterine abnormalities and patency of the fallopian tubes

most common cause of postpartum hemorrhage, and next step

uterine atony. first step- uterine massage to check if the uterus is boggy. if uterus is firm, consider genital tract laceration

most common cause of postpartum hemorrhage with a firm uterus

genital tract laceration

what to look out for w/ tubo-ovarian abscess (life threatening)

rupture! clinical present- shock with hypoTN (see hypotension, confusion, apprehension , and tachycardia), IMMEDIATE SURGERY

most common cause of a nontender infectious ulcer of the vulva, tx

syphilis. painless adenopathy is usually associated. IM penicillin

how to test for syphilis

serology (RPR or VDRL) and specific treponemal test. However a patient with primary sypilis may not have developed an antibody response yet so confirm with DARKFIELD MICROSCOPY

most common cause of mortality in a woman younger than 20 y/o

motor vehicle accidents

most common cause of mortality in a woman older than 39 y/o

cardiovascular diz

signs of placental separation

cord lengthening, gush of blood, globular uterine shape, uterus lifting up to the anterior abdominal wall

placenta doesnt delivery after 30 min now what

attempt manual extraction

what is the mechanism of hemorrhage for inverted uterus

inability for adequate MYOMETRIAL contraction effect. myometrial fibers do not exert their normal tourniquet effect on spiral arteries

best therapy for patient whose uterine fundus cannot be repositioned after uterine inversion (because the cervix is tightly contracted and physician can't get in there)

halothane anesthesia

Duhrssen incisions of the cervix are used to

treat the entrapped fetal head of a breech vaginal delivery

perimenopause/climacteric. when does it start. next step

between 40 and 51 yrs measure FSH and LH to check for elevation

premature ovarian failure

menopause before age 40 (ovarian follicular atresia). At ages below 30, consider autoimmune diz or karyotypic abnormalities

in menopause ovarian inhibin levles are decreased what's the consequence of this

FSH and LH levels rise before estradiol levels fall

An 18 y/o adolescent female with infantile breast development has not started her menses. She has some webbing of the neck region, streaked ovaries, adn elevated gonadotropin (LH. FSH) levels. What is this condition

Turner syndrome 45 XO, this pt likley has decreased estrogen which predisposes her to osteoporosis and other conditions later in life

Excessive exercise may lead to ___ dysfunction, but many times simple weight gain will lead to its restoration of function. What to do (apart from gaining weight)?

hypothalamic.
put pt on OCPs to maintain normal hypothalamic fcn

What two endocrine states may cause hypothalamic dysfunction, inhibit GnRH pulsations, and thus inhibit pituitary FSH and LH release

hypothyroidism and hyperprolactinemia. These cause HYPOESTROGENIC AMENORRHEA

a common cause of hyperprolactinemia in a 22 y/o girl is

prolactinoma. pt will likely be amenorrheic

amenorrhea due to hyperprolactinemia causes a ____ state due to decreased GnRH release, and decreased FSH and LH secretion

hypoestrogenic

most common location of an osteoporosis-asociated fracture

thoracic spine as a compression fracture

continuous estrogen-progestin therapy may be associated with a small but significnat risk of what 2 conditions

cardiovascular diz and breast cancer

pathophysiology of septic shock

vasodilation usu due to endotoxins, although Staph aureus has exotoxins as causative

inadequate powers, what's next

oxytocin

latent phase of labor is too long

PROLONGED latent phase

active phase of labor is too long

PROTRACTED active phase

clinically adequate uterine contractions

contractions everey 2 to 3 min, firm on palpation, and lasting for at least 40 to 60 secs OR 200 Montevideo units in 10 mins

most common decels are

variable, caused by cord compression

late decels suggest

fetal hypoxia and/or acidemia, due to uteroplacental insufficiency

what pelvis type predisposes to the persistent fetal occiput posterior position

anthropoid- AP diameter greater than transverse diameter with prominent ischial spines and narrow anterior segment

what is 0 station

presenting part (biparietal diameter) right at the plane of the ISCHIAL SPINES

bloody show

loss of cervical mucus plug. sign of impending labor. sticky mucus admixed with blood

best tools for evaluating possible ectopic pregnancy

hCG levels and TVUG

hCG threshold

1500 to 2000 mIU/ml. should be able to see an intrauterine pregnancy with this hCG level, which should be achieved by 5 wk GA

progesterone level to indicate a normal intrauterine gestation

greater than 25 ng/ml

progesterone level to indicate a nonviable gestation

less than 5 ng/ml

most significant risk factor for the development of an ectopic pregnancy

prior chlamydial cervical infection

RH-negative women with threatened abortion, spontaneous abortion, or ectopic pregnancy should get what

Rhogam to prevent isoimmunization

threatened abortion. hCG level is greater than us threshold, what do you do next?

TVUS

threatened abortion. hCG level is greater than us threshold. you did TVUS and see no intrauterine pregnancy, what do you do next?

laparoscopy. DO NOT GIVE METHOTREXATE BECAUSE THERE COULD BE A BABY IN THERE (15% of time)

threatened abortion. hCG level is lower than us threshold. what next?

measure hCG in 48 h it should rise by 66%

threatened abortion. hCG level is lower than us threshold. you measured hCG 48 h later and it rose by 66%. what next?

probably a viable IUP, so repeat sonogram when hCG exceeds threshold

threatened abortion. hCG level is lower than us threshold. you measured hCG 48 h later and it did not rise by 66%. in fact it only rose by 20%what next?

probably nonviable pregnancy. UTERINE CURETTAGE

threatened abortion. hCG level is lower than us threshold. you measured hCG 48 h later and it did not rise by 66%. in fact it only rose by 20%so you did a uterine curettage and found chorionic villi on pathology. what next?

this is a MISCARRIAGE aka SPONTANEOUS ABORTION. three choices- (1) expectant management, (2) D&C, (3) vaginal misoprostol

threatened abortion. hCG level is lower than us threshold. you measured hCG 48 h later and it did not rise by 66%. in fact it only rose by 20%so you did a uterine curettage and found NO chorionic villi on pathology. what next?

this is an ECTOPIC PREGNANCY. If it's asymptomatic, small (<3.5 cm) then do IM methotrexate

Woman at 5 wks gestation with severe lower abdominal pain who is hypotensive and tachycardic, TVUS shows free fluid in cul-de-sac what next?

RUPTURED ECTOPIC PREGNANCY likely, she is in shock, do surgery immediately. Forget about methotrexate

next management step for placenta accreta

hysterectomy

risk factors for placenta accreta

placenta previa, implantation over the lower uterine segment, prior c/s scar or other uterine scar, uterine curettage, FETAL DOWN SYNDROME

pt has placenta previa or low-lying placenta dx in 2nd trimester. what to do?

do another us in 3rd trimester, because it may resolve as the lower uterine segment grows more rapidly, this is known as transmigration of the placenta

what is the most likely complication after high ligation of umbilical cord and IV methotrexate therapy as a management option of placenta accreta, in order to avoid hysterectomy?

coagulopathy/hemorrahage
the next complication is infection because necrosis of the placental tissue can be a nidus for infection

3 prior c/s with placenta previa are assoc with up to a __% risk for placental accreta

50

in placenta accreta, the ___ _____ layer of the uterus is defective

decidua basalis (endometrium)

intracellular gram negative diplococci on Gram stain

gonococcal cervicitis

tx gonococcal cervicitis

IM ceftriaxone for GC + oral azithromycin or doxycycline for chlamydia. If it's GC treat G and C. If it's C only treat C.

mucopurulent cervicitis

yellow exudative discharge arising from the endocervix with 10 or more PMNs per high power field on microscopy

the most common organism implicated in mucopurulent cervical discharge is

Chlamydia trachomatis

most commono cause of septic arthritis in young women

gonorrhea

Why is Chalmydia not a common cause of pharyngitis like Neisseria is?

b/c Neisseria has pili that allow it to adhere to surface of columnar epithelium at back of throat. Chlamydia doesn't

Gonococcal infections usually present when- neonate

between 2nd and 5th days of life

Chlamydial infections usu present when- neonate

between 5th and 14th days of life

completed abortion. what next

follow hCG levels to Zero

clinical picture of completed abortion

passage of tissue, resolution of crampling and bleeding, closerd cervical ox

most common cause of spontaneous abortion

chromosomal abnormality

threatened abortion

pregnancy less than 20 weeks gestation assoc with vaginal bleeding, w/o cervical dilation

inevitable abortion

pregnancy less than 20 weeks gestation assoc with cramping, bleeding, and cervical dilation. No passage of tissue

incomplete abortion

pregnancy less than 20 weeks assoc with crampling, vaginal bleeting, open cervical os, and some passage of tissue but also some retained tissue. Cervix remains open due to continued uterine contractions

missed abortion

pregnancy less than 20 weeks with embryonic or fetal demise but no bleeding or crampling

difference between inevitable abortion and incompetent cervix

inevitable abortion- uterine contractions lead to cervical dilation
incompetent cervix- cervix opens spontaneously without uterine contractions. Painless cervical dilation.

treatment of incompetent cervix

cerclage- surgical ligature at internal cervical os

tx incomplete abortion

D&C

pt has complete molar pregnancy. treatment?

uterine suction curettage

pt has complete molar pregnancy, undergoes uterine suction curettage, what next

follow pt with weekly hCG levels because sometimes gestational trophoblastic diz persists after evacuation of the molar pregnancy

pt has complete molar pregnancy, undergoes uterine suction curettage, pt is followed with weekly hCG levels and they stay elevated showing that the gestational trophoblastic diz is persistent. what next?

chemotherapy

cervical conization is a risk factor for

incompetent cervix

two most common causes of antepartum (at or after 20 wks gest) bleeding

placenta previa and placental abruption

antepartum bleeding

bleeding at or after 20 wks gestation

Erb palsy, how is it usually caused, what nerve roots are affected, what muscles are weak, appearance of affected arm

downward traction of anterior shoulder, C5-6, deltoid infraspinatus forearm flexors, limp by side and internally rotated (waiter's tip)

what maneuver should be avoided with shoulder dystocia

applying fundal pressure it increases injury

maneuvers for shoulder dystocia

McRoberts (hyperflex maternal thighs against abdomen) and suprapubic pressure- first ones to try
then Wood's corkscrew (progressively rotate posterior shoulder 180 degrees in a corkscrew fashion), delivery of posterior arm, Zavanelli maneuver (cephalic replacement and immediate c/s)

how does the McRoberts maneuver work

causes anterior rotation of symphysis pubis and flattening of lumbar spine. This relieves the anterior shoulder from impaction

how does the suprapubic pressure maneuver work

moves fetal shoulders from AP to oblique plane, allowing the shoulder to slip out from under the symphysis pubis

most common injury to the neonate ina shulder dystocia

brachial plexus injury such as Erb palsy

ureteral injury after hysterectomy. best exam

intravenous pyelogram (IVP). (CT scan of abdomen with IV contrast is okay)

percutaneous nephrostomy

placement of a stent into the renal pelvis through the skin under radiologic guidance to relieve urinary obstruction

risk factors for ureteral injury

cancer, extensive adhesions, endometriosis, tubo-ovarian abscess, residual ovaries, interligamentous leiomyomata

most common location for ureteral injury

at the CARDINAL LIGAMENT where the ureter is only 2-3 cm lateral to the cervix (water under the bridge)

overdissection of the ureter may lead to

devascularization injury. urine can be leaked into abdominal cavity and cause irritation to the intestines, inducing n/v

66 y/o woman with postmenopausal vaginal bleeding what are you concerned about? what should you do?

endometrial cancer
endometrial biopsy

postmenopausal bleeding REQUIRES you to do what?

endometrial biopsy to assess for endometrial cancer

postmenopausal bleeding. pt has many risk factors for endometrial cancer. however endometrial biopsy/sampling is negative for cancer. what next?

hysteroscopy to directly visualize endometrial cavity

how is endometrial sampling (biopsy) done

a thin catheter is introduced through the cervix into the uterine cavity under some suction to aspirate endometrial cells. It is doe in the office

msot common cause of postmenopausal bleeding

atrophic endometrium 2/2 low estrogen levels (HOWEVER anytime there is postmenopausal bleeding you must biopsy and test for endometrial cancer)

Endometrial strip greater than ____ is abnormal in a postmenopausal woman

5 mm in thickness

what type of younger woman can be affected with endometrial cancer?

woman with h/o PCOS or other chronic anovulation

risk factors for endometrial cancer

too much or unopposed estrogen (early menarche and late menopause, obesity, chronic anovulation, estrogen-secreting ovarian tumors, ingestion of unopposed estrogen)
HTN
DM
personal or family hx of breast or ovarian cancer

most common femal genital tract malignancy?

endometrial carcinoma

staging procedure for endometrial cancer includes

TAHBSO, omentectomy, lymph node sampling, peritoneal washings

atypical GLANDULAR cells on the Pap smear may indicate what

endocervical OR endometrial cancer

what is the primary tx for endometrial cancer. how do you treat when staging shows high suspicion of spread? how do you treat when staging shows metastasis? what is the role of progestin in tx?

surgical (also is done for staging). radiotherapy. chemotherapy. no role- ineffective once endometrial cells become complex and atypical, because even though it is effective in shedding the endometrial lining it cannot inhibit cellular proliferation

placental previa. next step? long term management?

ultrasound exam; expectant management as long as bleeding is not excessive, c/s at 36 to 37 weeks' gestation after an amniocentesis is done to establish fetal lung maturity

risk factors for placenta previa

grand multip, prior c/s, prior uterine curettage, previous placenta previa, multiple gestation

woman presents with a placenta previa picture. What is the order of examinations?

us exam (rule out previa), speculum exam (Assess cervix and look for lacerations), digital exam (dont do a blind digital exam you could further separate the placenta from the uterus and cause more bleeding)

major risk factors for placental abruption aka abruptio placentae

trauma such as motor vehicle accident (MOST SIGNIFICANT), HTN- chronic and preeclampsia, cocaine use.

other risk factors for placental abruption

short umbilical cord, uteroplacental insufficiency, submucous leiomyomata, sudden uterine decompression (hydramnios), cigarette smoking, PPROM (preterm premature rupture of membranes)

Couvelaire uterus

bleeding into the myometrium of uterus giving a reddish discolored appearance to the surface. occurs in placental abruption

At delivery there is a blod clot adherent to the placenta, what has happened

placental abruption

coagulopathy in placental abruption is secondary to

hypofibrinogenemia

hallmark of placental abruption

painful vaginal bleeding

other things that may present with placental abruption (it has a variable presentation and is thus hard to diagnose)

preterm labor, stillbirth, FHR abnormalities

lab tests for placental abruption

serial hemoglobin levels
Kleihauer-Betke (Apt) test- tests for fetal erythrocytes from maternal blood because fetal-to-maternal hemorrhage is more common with abruption

how does the Kleihauer-Betke (Apt) test work?

Fetal Hgb is resistant to base, adult is not. Expose blood to NaOH, adult Hgb will be denatured (yellow-brown) and fetal will not (pinkish)

best diagnostic procedure when a cervical lesion is seen

cervical biopsy (not Pap smear)

most common presenting sympton of invasive cervical cancer

abnormal vaginal bleeding

woman has abnormal vaginal bleeding, flank tenderness, and leg swelling what do you think of?

advanced cervical cancer (metastasis)

risk factors for cervical cancer

early age of coitus and childbearing, STDs, poor, HPV, HIV, smoking, multiple sex partners

majority of cervical dysplasia dn cancers arise near the

squamocolumnar junction of the cervix

CIN lesions, what happens when 3% or 5% acetic acid solution is applied

acetowhite change

tx early cervical cancer; advanced cervical cancer

surgery (radical hysterectomy) or radiation therapy; radiotherapy (brachy and teletherapy) + cis-platimum chemotherapy to sensitize tissue to radiotherapy

most common cause of death due to cervical cancer

bilateral ureteral obstruction leading to uremia

how does cervical cancer spread to the ureters

through the cardinal ligaments toward the pelvic sidewalls

staging procedure for cervical cancer

examination under anesthesia, IVP, CXR, barium enema or proctoscopy (examination of anus and rectum), cystoscopy

Pap smear. you see ASCUS what next?

HPV typing

Pap smear. you see LSIL or HSIL. what next?

colposcopy-directed biopsy with endocervical currettage (LEEP or cone biopsy). HPV typing is not indicated

adolescent or pregnant woman. Pap smear. You see ASCUS, what next?

can observe, or can do HPV testing

amenorrhea

no menses for 6 months

the pituitary necrosis in Sheehan syndrome is ___

hemorragic/pressure
(not ischemic)

most common cause of amenorrhea in the reproductive years

pregnancy

most appropriate initial test for amenorrhea in the reproductive years (premenopausal)

pregnancy test (beta hCG)

hypothalamic causes of amenorrhea

hypotheyroidism, hyperprolactinemia

amenorrhea in pt who is obeses or has h/o irregular cycles, what do you think of

PCOS

positive progestin withdrawal bleed (vaginal bleeding after the ingestion of a progestin such as medroxyprogesterone acetate or Provera) is consistent with

PCOS

Common LH:FSH in PCOS

2:1 (think LH has 2 letters)

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