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Excessive menstrual flow

Menorrhagia

Features of menstrual history

Age of menarche
Character of menstrual cycles (time)
Quantity (length)

Irregular and heavy menses

Menometrorrhagia

ROS in pregnant women

Headache
Visual disturbances
Epigastric pain
Facial swelling

All pregnant women >20 weeks

Vulvar mass at 5 or 7 oclock

Bartholin gland cyst or abscess

Lab assessment fo rthe obstetric patient

CBC
Blood type
HBsAg
Rubella titer
RPR --> MHATP or FTA-ABS
HIV
Urine culture or U/A
PAp smear
Endocervical assays for gonorrhea and/or chlamydia trach

Screen for neural tube or Down syndrome when

B/w 16-20 weeks gestation

Screen for GDM when

26-28 weeks, using a 50g oral glucose tolerance test after 1 hour

GBS cultures

Introital cultures obtained at 35-37 weeks gestation

Tests for menorrhagia due to uterine fibroids

CBC
Endometrial biopsy --> performed to assess for endometrial cancer and pap smear for cervical dysplasia or cancer
Pap smear

Woman >55 yo, adnexal mass

CA-125, CEA tumor markers

Risk factors for GBS

Testing + for GBS late in current pregnancy
Detecting GBS in urine during current pregnancy
Delivering early (before 37 weeks gestation)
Developing fever during labor
Having long period b/w water breaking and delivering
Having a previous infant with early onset disease

Strongest risk? Preterm delivery, esp for late onset disease.

Physical exam findigns for genuine stress incontinence

Hypermobile urethra
Cystocele
Loss of urethrovesical angle

Treatment for genuine stress incontinence

Kegel exercises and timed voiding

Unsuccesful? Urethropexy (surgical fixation of proximal urethra above the pelvic diaphragm), suburethral sling, or transobturator, or transvaginal fixation.

Genuine stress vs urge incontinence

Genuine stress - loss of urine with coughig sneezing or lifting with no delay

Features of overflow incontinence

Hx of diabetes or a neuropathy

Causes of overflow incontinence

Diabetes
Spinal cord injuries
Lower motor neuropathies
Urethral edema following pelvic surgery

Cystometric evaluation is used to distinguish between what

GSUI and UUI

Causes of genuine stress incontinence

Trauma and/or childbearing or other causes of weakness of pelvic diaphragm --> proximal urethra falls below the pelvic diaphragm.

Urethropexy does what

Surgical fixation of proximal urethra back to its intraabdominal position.

Urge incontinence mechanism

Uninhibited spasms of the detrusor muscle --> bladder pressure overcomes the urethral pressure. Dysuria or the urge to void are prominent symptoms, reflecting bladder spasms....

Coughing or sneezing can provoke but usually delay of several seconds noted before urine loss.

"Overactive bladder."

Initial eval for urinary incontinence

Hx
PE
Postvoid residual

Treatmetnt of urge incontinence

Anticholinergic medication to relax detrusor muscle (surgery may worsen)

History feature of urge incontinence

"I have to go to the bathroom and I can't make it in time"

Treatment for overflow incontinence

Intermittent self catheterization

Signs of a fistula

Constant leakage after surgery or prolonged labor

How to diagnose a fistula easily

Dye into the bladder shows vaginal discoloration

Causes of neurogenic bladder

aka Overflow incontinence

Longstanding DM, spinal cord injury, multiple sclerosis

Patients generally do not feel the urge to void, large amounts of urine accumulated.

Medication for overflow incontinence

Bethanechol (muscarinic antagonist)

Approach to health maintenance

Cancer screening
Immunizations
Addressing common diseases

Thyroid function testing parameters

q5y

At what point are pap smears not cost effective

65

Fasting blood sugar testing parameters

q3y at age 45

Women <20, most common cause of mortality

MVA

Women >39, most common cause of mortality

Cardiovascular disease

Four signs of placental separation

Gush of blood
Lengtheninfo the cord
Globbular and firm shape of the uterus
Uterus rises up to the anterior abdominal wall

Appearance of the prolapsed uterus.

Reddish bulging shaggy mass

Vagina and cervical tissue may also prolapse but these will be smoother.

What is the third stage of labor

Delivery of infant to the delivery of the placenta

How long should the third stage of labor last?

30 minutes

Who is at particular risk for uterine inversion

Grand multiparity in which the placenta is implanted in the fundus (top of uterus)
Placenta accreta

Treatment for uterine inversion

Alert anesthesiologist (halothane and/or emergency surgery may be needed)
Two IV lines --> profuse hemorrhage)
Terbutaline or Mag sulfate
Upon reducing --> stop relaxation agents, start oxytocin or other uterotonic agents.
Place your fist insidethe uterus before you think it's reduced..

What type of placental implantation most likely predisposes to an inverted uterus?

Fundal

If the placenta doesn't deliver after 30 minutes...

Manual extraction of placenta should be attempted.

Mechanism for massive hemorrhage seen in inverted uterus

Inability for an adequate myometrial contraction effect. Myometrial fibers cannot exert their normal tourniquet effect on the spiral arteries. Basically a state of uterine atony.

Nonreducible uterus, best therapy

Uterine relaxing agent such as halothane anesthesia. Terbutaline or magnesium.

Entrapped fetal head of a breech vaginal delivery

Duhrssen incision

Most common cause of uterine prolapse

Traction on spinal cord
Can also occur spontaneously

Two uterine signs of pending placental separation

Globular shaped uterus
Uterus rising to anterior abdominal wall

Perimenopause aka

Climacteric state

FSH and LH rise in premenopause even before estrogen levels fall, why>

Because ovarian inhibin levels are decreased.

IF estrogen is not a choice in the treatment of hot flashes

Clonidine

FSH levels respond to what

Inhibin and not estrogen, so FSH cannot be used to titrate estrogen therapy.

51 yo woman with oligomenorrhea and hot flushes

Ovarian failure

22 yo nonpregnant woman with galactorrhea and hyperPRL

Pituitary adenoma (prolactinoma)

25 yo woman slightly obese, slightly hirsute and with a long history of irregular menses

Estrogen excess in the setting of PCOS. Often prescribed progesterone --> induce vaginal bleeding and to prevent endometrial hyperplasia

Turner sydnroem mechanism for oligomenorrhea

Turner syndrome --> ovarian failure, basically early FSH and LH rises. Most likely also has decreased estrogen levels as well --> osteoporosis and other complications.....

How are thyroid and prolactin stuff connected

Hypothyroidism can lead to hyperprolactinemia, but not vice versa (TRH can stimulate the release of PRL).

Most common location for an osteoporosis-related fracture

Vertebral compression fracture

Goal MAP in septic shock

>65

"Flesh eating bacteria"

Group A strep

MAP calc

(2*DBP) + SBP/3

Septic shock initially presents how

Decreased urine output

Septic shock hypotensiont hat does not resolve with IV fluids

Pressors --> NE for instance.

Definition of at term

37-42 weeks

Nulliparous cervical change expectations

1.2cm/h during active phase of labor

Multiparous cervical change expectations

1.5cm/h during active phase of labor

Definition of arrest of active phase

No progress in active phase of labor for 2 hours.

Stages of labro

First: onset to complete dilation of cervix
Second: Complete cervical dilation to delivery of infant
Third: Delivery of infant to delivery of placenta

Definitions of accelerations

Increase 15 above baseline for at least 15 seconds.

Latent phase of labor

Initial part, where cervix mainly effaces (thins) rather than dilates

FHR baseline

110-160

When a labor abnormality is diagnosed, what should be assessed

Powers
Passengers
Pelvis

Powers problem with labor

Oxytocin


If the powers are adequate --> Cesarian delivery

How long should the second stage of labor laast

Null - <2hr but <3 if epidural
Multi - <1h but <2h if epidural

Definition of clinically adequate uterine contractions

q2-3mins
Firm on palpation
Lasts 40-69 seconds

What are montevideo units

Sum of amplitudes above baseilne of the contractions within a 10 minute window

Upper limit for latent labor phase

14 hours

How to characterize an anthropoid pelvis

Pelvis with an AP diameter greater than the transverse diameter w/ prominent ischial spines and a narrow anterior segment.

Latent vs active taking too long

Prolonged latent labor
Protracted active labor (<1.5cm/h or 1.2 for nulliparous).

Bloody show?

Blood + mucus from mucus plug... mucus can help differentiate bloody show from anterpartum bleeidng

Causes of antepartum bleeding

Placenta previa
Placental abruption
Vasa previa

Adequate uterine contractions

>200 montevideo units
q2-3 minutes
Lasting at least 40-60 seconds

hCG level by which a transvaginal US should reveal an intrauterine pregnancy

1500-2000

Lower ab pain + vaginal spotting

Ectopic pregnancy until proven otherwise

Threatened abortion

Pregnancy with vaginal spotting during the first half of pregnancy. Does NOT delineate the viability of the pregnancy.

HCG, what is measured

Beta subunit of HCG, this is assayed to prevent CXR with LH

HCG levels >1500-2000 but no intrauterine pregnancy on US

Ectopic pregnancy highly probable.

HCG below 1500-2000, US findings equivocal

Serial HCG... if rises >66%.... then most likely has normla intrauterine pregnancy.

If it does not... if it rises by say, 20%, most likely has abnormal pregnancy. Could be ectopic or an SAB (may distinguish via uterine curettage... some people might anyway...)

Anotehr lab besides serial HCG for assessing a normal intrauterine pregnancy

Single progesterone level.... Levels>25 ng/ml --> normal.
Levels<5 --> Nonviable gestation.

MTX treatment for ectopics

Asymptomatic, small (<3.5 cm) ectopic pregnancies

Nonviable intrauterine pregnancy management

Expectantly
Surgically via dilation and curettage
Medically via vaginal misoprostol (effective in about 80% of cases)

HCG above threshold with no uterine things, symptomatic (volume depleted, hypotension, severe ab/pelvic pain/adnexal mass).

High risk of ectopic pregnancy (85%), and thus laparoscopy is often undertaken to diagnose and treat the ectopic pregnancy....

Rhogam when

28 weeks routine
Whenever there is a threatened abortion, spont abortion, or ectopic pregnancy discovered.

Side effects of MTX treatment for ectopic pregnancy

Mild abdominal pain which may be observed in the absence of severe peritoneal signs of hypotension or overt signs of rupture.

Pain of resolution typically much milder than pain of rupture!

What increases the risk of placenta accreta

Uterine incisions
Low lying placentation or placenta previa
Uterine curettage
Fetal down syndrome

Placenta accreta histologic definition

Abnormal adherence of the placenta to the uterine wall, due to an abnormality of hte decidua basalis layer of the uterus. Placental villi are attached to the myometrium.

Placenta increta

Abnormally implanted placenta penetrates into the myometrium

Placenta percreta

Through the myometrium to the serosa, often invasion into the bladder is noted.

Signs of placenta accreta

No cleavage plane found during attempts at manual removal of the placenta.

Positions assoc with placenta accreta

Anterior
Low lying in position

Placenta prvia diagnosed in second trimester, what might happen

May resolve in the third trimester as the placenta grows more rapidly, called "transmigration of the placenta."

Three prior cesarians with placenta previa are associated with what risk of accreta

50% risk!

Blue tissue densely adherent b/w uterus an dbladder

Very characteristic of percreta, where placenta penetrates all the way through the

Complications of gonorrhea

Salpingitis  infertility, ectopics. Disseminated gonorrhea is also possible.

Salpingitis sx

Adnexal tendernesss

Treatment regimen for gonorrhea

Ceftriaxone 125mg-250mg IM

Chlamydia regimen

Azithromyin 1g orally, or Doxy 100mg BID for 7-10 days

Definition of mucopurulent cervicitis

Yellow exudative discharge arising from the endocervix with 10 or more PMNs/HPF.

Division between lower and upper genital tracts

Cervix-Uterus

Postcoital spotting + discharge

Think cervicitis, GC or Chlamydia

Most common organism implicated in mucopurulent discharge

C. trachomatis

Gram stain in the utility of GC vs CT

Gram stain negative? Chlamydia more likely to be primary infection

Classic characteristic of gonococcal arthritis

Migratory

Disseminated gonococcal disease

Eruptions of painful pustules with an erythematous base on the skin. Also, fever, malaise, chills, joint pain and joint swelling.

Why is mucopurulent discharge mucopurulent

Involvement of columnar (mucus producing) glandular cells of the endocervix.

Salpingitis causes

GC, Chlamydia, GNRs, Anaerobes

Risk factors for salpingitis

Use of an IUD
Prev infection with GC or chlamydia
Surgery
Anything that breaks cervical barrier and enhances transfer of organisms from endocervix to the upper reproductive tract

Actinomyces in gynecology

Considered part of normal vaginal flora, is associated with IUD use but is not commonly encountered

Which is more likely to cause a sexually transmitted pharyngitis?

GC. Because it has pili that allow it to adhere to surface of the columnar epithelium at the back of the throat.

Can you culture the pustules of disseminated GC

Yes, yes you can

STD effects on the newborn

GC and chlamydia both may cause conjunctivitis and blindness in a newborn. GC usually presents b/w 2nd and 5th days of life, whereas chlamydial infections present b/w 5th and 14th

PAssage of tissue + resolution of cramping and bleeding + closed cervix

Completed abortion

But should still follow HCG

HCG trends in abortion

Should halve every 48-72 hours. If HCG levels plateau instead of falling --> residual pregnancy tissue....

Why is AMA assoc with more spontaneous abortions

Chromosomal abnormalities, are the most common cause identified with spotaneous abortion.

Threatened abortion

<20w GA
Vaginal bleeding w/o cervical dilation

Inevitable abortion

<20w GA
Cramping, bleeding, cervical dilation. No passage of tissue.

Incomplete abortion

<20w GA
Cramping, vaginal bleeding, open cervical os
Some passage of tissue, but some retained in utero.

Completed abortion

<20w GA
All POC has been passed, Cervix, is closed, symptoms have abated.

Missed abortion

<20w GA
Embryonic or fetal demise
No sx such as bleeding or cramping.

Threatened abortion, what should you tell the patient on the phone

BRing in any tissue-like substance passed for analysis.

Inevitable abortion should be differentiated from what

Incompetent cervix.

Contractions precede dilation in inevitable abortion. Incompetent cervix has spontaneous opening of the cervix withtou pain....

Presence or absence of uterine contractions!!

Treatment of incomplete abortion

D&C of the uterus. Primary complications of persistently retained tissue are bleeding and infection.

Threatened abortion, rate of miscarriage

50%.

Treatment of inevitable abortion

D&C vs expectant mgmt

Treatment/mgmt of complete abortion

Trend HCG

Clinical presentation of molar pregnancy

Vaginal spotting
Absence of FHT
Size greater than dates
Markedly elevated HCG levels

How to confirm diagnosis of molar pregnancy

"Snow storm" appearance by ultrasound

Treatment for elevated HCG even after D&C of molar pregnancy

Chemotherapy!

Hallmark of cervical incompetence

Painless dilation of the cervix

Risk factor for incompetent cervix

Congenital - short cervix or collagen disorders
Trauma to the cervix
Prolonged second stage of labor
Uterine overdistention with multiple gestation pregnancy.

Complications of retained POC

Bleeding infection, DIC.

Incomplete abortion, mgmt

D&C with sending of POC to pathology.

HCG threshold when a gestational sac should be seen on transvaginal ultrasound

1500-2000

Expected rise in HCG in a normal pregnancy in 48h

66%. If less, think abnormal.

Definition of antepartum bleeding

Bleeding >20 weeks

Most common causes of antepartum bleeding

Placenta previa
Placental abruption --> abdominal pain is usually severe.

Most common cause of first trimester miscarriage

Karyotype abnormality.

Uterine size in molar pregnancy

Size greater than dates.

First step in management of apparent shoulder dystocia

McRoberts maneuver --> hyperflexion of the maternal hips onto the maternal abdomen and/or suprapubic pressure.

Nonmanipulation of the fetus!! Avoid fundal pressure!!! Increased associated neonatal injury.

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