HTN Prior placental abruption Chronic hypertension Pregnancy-induced hypertension Cocaine EtOH or tobacco use Vascular disease sucha s DM and SLE
Most significant risk factor for placental abruption
HTN Sustained >160/110 treat pharmacologically
Uncontrolled maternal HTN
FUGR Oligohydramnios Abruption
Risk factors for placental previa
Prior c-delivery Multiparity Multiple gestation Advanced maternal age
Uterine atony --> hemorrhage risk factors
Multiple gestation Polyhydramnios
Night sweats, irregular menses, insomnia in a middle aged woman
Hormone changes during menopause
Decrease in estrogen resulting in decrease in the feedback inhibition ont he hypothalamic-pit axis --> elevation of FSH and LH
Menopause how to diagnose in the absence of lab values
>45 age 12 month history of amenorrhea without other physiologic causes
US reveals solid ovarian tumors, pregnant vs nonpregnant management?
Pregnant - benign luteoma, which usually appears as b/l multinodular solid masses on both ovaries. Replacement of noraml ovarian parenchyma by a solid prolifeartion of luteinzed stromal cells under the influence of HCG... Most common in AA multiparous women in 30s and 40s. Often asymptomatic... but 1/3 develop sx of hirsutism and virilization.... often benign and self limited and requires no treatment.
Nonpregnant --> needs biopsy and aggressive eval, because they are almost always malignant.
Solid ovarian tumors in pregnant
Classic luteoma of pregnancy. Most common in AA multiparous women. Often asymptomatic, but in 1/3 of patients hirsutism and virilization can develop. Benign and self limited, req NO treatment.
2/2 low FSH LH concentrations Can result from strenuous exercise, anorexia nervosa, marijuana use, starvation, stress, depression, and chronic illness.
FSH and LH drop--> estrogen and testosterone drop --> osteoporosis and decreased muscle mass. Patients will often suffer infertility.
Connection between hypogonadotrophic hypogonadism and hypothyroidism
Can be direct result of hypothyroidism, or be the result of a condition that is also causing hypothyroidism (pituitary pathology).
Atypical endometrial hyperplasia cause
Excessive levels of circulating estrogens or estrogen-like compounds.
Risk factors for gout
Male gender Diuretic use EtOH Obesity Diet rich in purines (organ meats, game, seafood)
NOT at high risk for gout.
Major risk factor for ectopic pregnancy
PID (subsequent episodes increase risk markedly)
Dysfunctional uterine bleeding treatment
High dose estrogen
This is a diagnosis of exclusion!!
Triad of ectopic
Amenorrhea Abdominal pain Vaginal bleeding
Most importnat intervention for preventing spread of HIV from mother to child
Zidovudine treatment (NRTI), aka Azidothymidine, to mother throughout pregnancy and labor, as well as to the neonate for first 6 weeks of life...
Decreases rate of transmission by 70%..
Interventions that decrease mother to infant transmission of HIV
Zidovudine treatment of mother and neonate (70% decrease) Elective cesarean (50%), combine with above.
Premature ovarian failure characterized by
Amenorrhea Hypoestrogenism Elevated serum gonadotropin levels in women age <40 years
Amenorrhea of 3 months duration with FSH in menopausal range
Causes of premature ovarian failure
Accelerated follicular atresia Low initial number of primordial follicles
Most commonly idiopathic, but may also be due to mumps, oophritis, irradiation, chemotherapy... Can also be associated with autoimmune disorders such as Hashimoto thyroiditis, Addison disease, DM-I, pernicious anemia... this supports diagnosis that some cases of idiopathic premature ovarian failure are of autoimmune origin.
Treatment for infertility with PCOS
Clomiphene citrate (SERM) Metformin (may also be used to promote ovulationin patients, because insulin resistance seenin this condition may contirbute to inability to ovulate normaly)
TWO most common causes of hypopituitarism in teh postpartum period
HEadaches, visual disturbances, and pituitary failure. Can be difficult to distinguish from pituitary neoplasm
Infiltrative disorders of the pituitary typically present with what
Sheehan syndrome presentation
In the few months following birth, lethargy, weight gain, fatigue, amenorrhea, dry skin, delayed tendon reflexes........
Aromatase deficiency results in what
Lack of enzymes that converts androgens into estrogens, and thus low estrogens...
In utero, placenta does not make estrogens and thus high level of androgens --> virilization of mother that resolves after delivery... high level of gestational androgens result in virilized XX child with normal internal genetalia but ambiguous external genitalia...
Baby born with clitoromegaly, what is the cause usually
Often seenwhen excessive androgens are present in utero.
Aromatase deificency signs nad sx
Normal internal genitalia Ambig external genitalia Clitoral hypertrophy High FSH/LH w/ low estrogen.
Normal internal genitalia (female) w/ ambiguous external genitalia, low estrogen
Most common cause of CAH
21 hydroxylase deficiency. Also have salt wasting...
Galactose-1-phosphate accumulation i nliver, brain, kidney --> cirrhosis, mental retardation, and Fanconi syndrome
Deficiency which causes gestational maternal virilization
Vulvar skin is thin, dry, and white in color
Lichen sclerosus (lichen sclerosus et atrophicus), an autoimmune phenomenon...
Anogenital discomfort with pruritus, dyspareunia, dysuria, and painful defecation..
Long term effects of Lichen sclerosus
Sclerosus and scarring --> obliteration of the labia minora and clitoris and a decrease in the diameter of the introitus.
Vulvar SCC -->occurs more commonly in women w/ LS&A. Punch biopsy of any suspicious lesions should be performed.
Estrogen cream good for what
Menopause-related atrophic vaginitis, which can also be a cause of vaginal pruritus and dyspareunia
Treatment of lichen sclerosus et atrophicus
Considered a premalignancy, so surveillance with reg clinical exams and biopsies
High potency steroids (few conditions for which this is encouraged), because it is a chronic inflammatory condition.
Doxycycline OR Azithromycin
Polymicrobial infection such as postpartum endometritis
Presence of feto-maternal hemorrhage, what test?
Rosette test.... Treat matenral blood with anti-Rh, then R2R2 cells.
If negative administer anti-D immune globulin as per usual. If positive, amount of hemrorhage can be evaluated with a Kleihauer-Betke stain or fetal red cell stain using flow cytometry and the dose of Anti-D immune globulin should be adjusted accordingly.
Test for feto-maternal hemorrhage
When should standard dose of Anti-D be administered in an uncomplicated pregnancy
28 weeks, again at delivery. Risk of alloimmunization before 28 weeks is very low.
Amniotic fluid embolism is a well recognized complication of what
Amniocentesis. Presents with sudden respiratory failure, is often accompanied by cardiogenic shock and seizures.
Feared complication of Amniotic Fluid Embolism
Immediate management of amniotic fluid embolism
Adequate respiratory support. Facemask ventilation, or intubation.
Abrupt onset of hypoxia, respiratory failure, cardiogenic shock, and DIC
Symptoms in endometriosis
When sx: chronic pelvic pain that is worse in premenstrual period, dysmenorrhea and pain with sexual intercourse or defecation. Exam: rectovaginal tenderness or tenderness with mvoement of the uterus due to presence of ecotpic endometrial tissue in the rectovaginal septum and pelvic peritoneum... blah blach blach.
Gold standard for diagnosis of endometriosis
Connection between infertility and endometriosis
Up to 30% of females being evaluated for infertility are found to have endometriosis
Mechanisms for infertility in endometriosis
Adhesion formationw/i peritoneum that interferes wtih the normal transfer of oocytes from the ovaries to the fallopian tube Endometrial factors within uterus that may provide suboptimal environment for implantation Hormonal stuff that have yet to be determined
Risk factors for endometrial cancer
Advancing age Use of unopposed estrogen in the past Prolonged use of tamoxifen Obesity Nulliparity PCOS (Stein-Leventhal)
Risk factors for breast cancer
EArly menarche Late menopause Nulliparity
aka Multiple hamartome syndrome
Increase in hamartomas, and increased risk of certain forms of cancer....
Loss of function mutation in PTEN, a TSG that leads to hyperactivity of mTOR...
Cowden syndrome s/sx
Macrocephaly Intestinal hamartomatous polyps Acral keratoses Dysplasti gangliocytoma of the cerebellum --> Lhermitte-Duclos disease
Cowden syndrome, predilection to what cancers
Breast carcinoma Follicular carcinoma of the thyroid Endometrial carcinoma
What increases risk of abruptio placentae
HTN Cocaine Smokers Advanced age Preeclampsia
Risk for preterm labor
Prior preterm labor Multiple gestation Premature rupture of membranes Exposure to diethylstilbestrol
Dysfunctional uterine bleeding, how to diagnose
Heavy vaginal bleeding that occurs in the absence of structural or organic disease... normal pelvic exam + negative pregnancy test --> DUB.
Steps in the w/u for DUB
Endometrial biopsy, to r/o endometrail hyperplasia or carcinoma....
Esp in >35 yo, obese, chronically hypertensive, or diabetic...
Risk factors for endometrial hyperplasia or carcinoma
>35 yo Obese Chronically hypertensive Diabetic
Treatment for DUB
Screen those with risk factors for endometrial business
Cyclic progestins... if that fails, endometrial ablation or hysterectomy.
Corticosteroid treatment for what GA
No benefit after 34 weeks, use is limited to 24-34 weeks. Additionally corticosteroids require 24-48 hours to have maximum benefit on fetal lung maturity
Atrophic vaginitis s/sx
Vaginal dryness Pruritus Dyspareunia Dysuria!! Urinary frequency
Pelvic exam in atrophic vaginitis
Pale, dry,and smooth vaginal epithelium Scarce pubic hair Loss of labial fat pad....
This results from decrased estrogenlevelss.
ATrophic vaginitis may be confused by symptoms for what
UTI (dysuria and urinary frequency)
Treatment for atrophic vaginitis
Mild - lotions, moisturizers
Mod-severe - low dose vaginal estrogen therapy
How to assess infertility due to aging
Early follicular phase FSH level Clomiphene challenge test Inhibin-B level
Signs of premature ovarian failure
<40 Amenorrhea, can also be caused by autoimmune conditions, heritable factors, exogenous factors such as radiation exposure, and as an idiopathic condition.
Most common cause of decreased fertility in fourth decade
AGe-related decreased ovarian reserve
Clinical: hirsutism, acne, or male pattern baldness or androgenic alopecia and/or biochemical high serum androgen concentrations Amenorrhea or oligomenorrhea Pelvic U/S with cystic ovaries, small cysts are noted around the ovaries in a classic "string of pearls" appearance.
Pelvic U/S with cystic ovaries
Small cysts are noted around the ovaries in a classic "string of pearls" appearance
Obesity and PCOS
PCOS risks for what
Infertility Insulin resistance DM-II Cardiovascular disease Endometrial cancer Dyslipidemia
PCOS patients should be screened for what
Insulin insensitivity DM-II
Do an OGTT
CA-125 good for what
Ovarian cancer (used to monitor therapy)
Causes of severe vomiting during pregnancy
Hyperemesis gravidarum Gestational trophoblastic disease (hydatidiform mole and choriocarcinoma)
Clinical course of hyperemesis gravidarum
Vomiting begins in weeks 4-10 GEnerally resolfves by mid pregnancy
Menstrual irregularities + Evidence of hyperandrogenism
Two things needed for PCOS
Menstrual irregularities Evidence of hyperandrogenism
PCOS risk for what
Adequate amount of active estrogens. Androgens will be converted into estrogens in the peripheral tissues. Deficient in progesterone secretion, and thus constant and unbalanced mitrogenic stimulation of the endometrium by estrogens leading to endometrial hyperplasia, intermittent breakthrough bleeding, and dysfunctional uterine bleednig.
Self-correction by the 37th week of gestation, thus no external version is recommended before that time.
Contraindications to external version for breech positioning
Placental abnormalities Fetopelvic disproportion Hyperextended fetal head
When should screening for GDM take place
High risk: first prenatal visit Others: 24-28 weeks
One hour 50g OGTT used as initial screening. If <140, GDM ruled out... If >140, three hour 100g OGTT is then performed Fast >95 One hour serum glucose >180 Two hour serum glucose >155 Three hour serum glucose >140
Androgen insensitivity syndrome
Testicular feminization --> defect or absence of androgen receptors resulting in androgen resistance of all peripheral tissues... Female phenotype with a 46XY. Still normla testes that are typically found in the abdomen or inguinal canal, and patients are prone to inguinal hernias....
MIF produced by testes, and prohibits formation of the uterus, fallopian tubes, and upper portion of vagina...
Breasts develop because of peripheral conversion of testosterone to estrogen, whereas axillary and puibic hair does not develop since it is dependent on testosterone.
Treatment: Testicular resection, creation of a neovagina.
Primary amenorrhea and nondeveloped internal reproductive organs,but normla XX karyotype with normal testosterone.... Normal axillary and pubic hair development since they respond appropriately to testosterone.
Sx of androgen resistance
Amenorrhea Normally developed breasts Absent pubic and axillary hair Absent internal organs 46XY karyotype
Who gets granulosa cell tumors
Bimodal age distribution. Young - Precocious puberty Old - Postmenopausal bleeding, uterine myohyperplasia, absence of vaginal atrophy
S/Sx of dysgerminoma
Neutral hormone-wise, may arise in younger women or children, average incidence 20. Occasionally they undergo torsion
S/Sx of sertoli-leydig cells
Androgen producing, causes defeminization followed by masculinization. May have altered body contour, flattening of breasts, scanty/irregular menstruation, ultimately ending in amenorrhea.... Hirsutism, coarsening of the features, enlargement of the clitoris.
Most common cystic ovarian neoplasms
Serous cystadenomas - 30% of all ovarian tumors. 25% of all these are malignant, and about half of the cases are bilateral. Usually do not produce estrogen or androgens...
Ovarian mass and abdominal pain are presenting features.
Chorionic villus sampling can be done when
10-12 weeks gestation....
Indicated in women over 35 yo with an abnormal US.
Slightly higher risk than amniocentesis
When is amniocentesis done
16-18th weeks gestation
There is also early amniocentesis<15weeks, reserved for those who cannot have chorionic villus sampling.
What is codocentesis
aka Percutaneous Umbilical Blood Sampling.... used for rapid karyotype analysis or when fetal blood dyscrasias such as fetal anemia and Rhesus isoimmunization are suspected.... Also for when mosaicism is suspected by CVS or amnio to further assess the fetal karyotype.
MSAFP good for screening for what
Neural tube and abdominal wall defects Chromosomal anomalies when serum levels of estriol and bHCG are also assessed....
First trimester way to detect fetal chromosomal abnormalities
Chorionic villus sampling.
Risks of CVS
Fetal death Limb reduction defects
Limb reduction defects are greatest when procedure is done before nine to ten weeks gestational age...
CVS done when
10-12 weeks gestation
Diethylstilbestrol exposure in utero predisposes to what in female offspring
Cell cell adenocarcinoma of vagina and cervix Cervical abnormalities (hypoplasia) Uterine malformations (T-shaped, small uterine cavity) Vaginal adenosis and vaginal septae
Many also have difficulty conceiving and maintaining pregnancy.
DES what is this
Diethylstilbestrol, used between 1947-1971 for the treatment of threatened abortion... Female offspring of treated women have higher risk of clear cell adenocarcinoma of the vagina and cervix among other thigns
Diethylstilbestrol predisposes male offspring to what
Beyond 32 weeks, hard to tell... though many centers continue to administer bethamethasone at gestational ages b/w 32-34 weeks for patients with PPROM. Glucocorticoids are typically not given after 34 weeks.
Most common type of precocious puberty
Idiopathic central precocious puberty, resulting from premature activity of H-P-G axis... They have pubertal levels of basal LH that increase with GnRH stimulation, whereas patients with peripehral source have no stimulation+ test....
Precocious puberty of central origin, next test
Brain imaging to r/o CNS lesion
Treatment for precocious puberty of central origin
What is Cyproterone acetate
Steroid-based compound with antiandrogenic and antigonadotropic effects, used in Europe second line for hirsutism.
Progestin-like med useful in the treatment of endometriosis and fibrocystic breast disease.
Inhibits secretion of gonadotropins, used for contraception and abnormal uterine bleeding.
Treatment for GDM
Diabetic diet SC Insulin (category B agent, does not cross placenta)
Maternal trauma Chronic hypertension Maternal smoking Hx of external cephalic version
SGA risk factors
Impaired placental perfusion Maternal smoking Alcohol or drug abuse Maternal malnutrition Multiple gestation Infections Genetic disorders Teratogen exposure
Gold standard for cervical eval
Transvaginal ultrasound - presence of funneling of cervix or shortening of the cervical length - should be more than 25 mm at 24 weeks..... <10th percentile - short cervix.
What is a reactive NST
20 mins - 2 FHR accels of at least 15 bpm lasting at least 15 seconds
Most common cause of nonreactive NST
Sleeping baby, not a diseased baby. Vibroacoustic stimulation used to wake up baby.b
US detection of abruption
Only detects 25% of cases More useful in ruling out placenta previa than in diagnosing abruption
Ovulatory phase mucus changes
Profuse, thin, clear. Stretches to approx 6cm when lifted vertically (spinnbarkeit). pH is 6.5 or greater and it will demonstrate ferning as well.
When cervical mucus stretches to approx 6cm when lifted verticaly
Early follicular phase immediately follows what
Young women presents with a breast lump, can ask to do what
Return after her menstrual period for reexamination if no obvious signs of malignancy are present. If it decrease in size after the menstrual period, probability of benign disease is very high.
After 36 weeks, what is the likelihood of spontaneous conversion to a cephalic presentation
When is ECV indicated
B/w 37 weeks and the onset of labor. Has been shown to reduce the rate of cesarean sections.
Risk of ECV
Potential to result in fetal distress, so it should only be performed when arrangements have been made to allow for an emergent cesarian delivery.
What is internal podalic version
Converting the second twin in a twin deliery from a transverse or oblique presentation to a breech presentation for subsequent delivery.
Genital warts aka
Condyloma acuminata (NOT LATA)
Lichen sclerosus presentation
Thin, white, and wrinkled skin over the labia, typically affecting postmenopausal females
Vulvar lichen planus presentation
Middle-aged women, lesions may be hyperkeratotic, erosive, or papulosquamous in appearance.... Pruritus, soreness, and vaginal discharge are common.
Cord compression, can occur from what
Oligo Nuchal cord
When do variable decels transition from intermittent to variable
Repetitive >=50% in a 20 minute period.
First step in NRHR
Administer oxygen Change maternal positioning
Also d/c uterotonic drugs, and eval/treat maternal hypertension.
Perhaps consider amnioinfusion for variable decels
Variable decels, possible treatment?
Fetal scalp pH for what
Fetal hypoxia, if the abnormal FHR pattern persists after initial measures of position change, oxygen administration, and d/c of oxytocin have been tried.
Transab vs transvaginal U/S for the evaluation of gestation
Transab cannot reliably visualize until betaHCG >6500
Transvag can see as low as 1500 bHCG, sometimes even as low as 800
What use are serial bHCGs for ectopics?
bHCG should double every 48 hours... if it doesnt, if it has a slower rise --> bHCG
Culdocentesis, what is this
Insertion of needle into the posterior vaginal wall to identify peritoneal fluid in the cul de sac.
bHCG 1500-6500, possible ectopic
Use transvaginal us instead of abdominal.
Septic retained POC, treatment
Cervical and blood cultures Antibiotics Gentle suction curettage (vigorous curettage please avoid b/c of risk of uterine perforation)
This is a medical emergency.
Pregnancy not at term, mild preeclampsia
Bed rest and close observration HTN usually responds, but methyldopa can be used to treat sustained BPs in excess of 160/110 Dexamethasone 24-34 weeks gestation should be considered
Window for dex
Mag sulfate in preeclampsioa
Pretty much only during labor and within 24 hours of delivery.
Fetal hydantoin syndrome
Can be caused by exposure to many anticonvulsants, most commonly phenytoin and carbamazepine
Characterized by: Midfacial hypoplasia Microcephaly Cleft lip and palate Digital hypoplasia Hirsutism Developmental delay
Congenital syphilis signs/sx
Snuffles HSM Skin lesions
Later signs!! Interstitial keratitis Hutchinson teeth Saddle nose Saber shins Deafness CNS involvement
Like FHS: midfacial hypoplasia, microcephaly, stunted growth
CNS damage, which may manifest as hyperactivity, MR, or learning diasbility..
NO CLEFT PALATE OR EXCESS HAIR.
Cocaine use effects on fetus
Placental abruption --> CNS dysfunction
Vaginal cancer treatment
Stage I and II (no extension to pelvic wall, no mets) <2 cm in size - removed surgically
Stage I and II >2 cm size - radiation therapy
Stage III and IV - combo chemotherapy, as well as tumors >4 cm in size...
Most common symptoms of vaginal cancer
Vaginal bleeding Malodorous vaginal bleeding
Preterm labor def
Labor >20 weeks and before 37 weeks.
Labor contractions >4 / 20 minutes or mroe and documented cervical changes consistent with labor.
Complications of preterm birth
RDS Intraventricular hemorrhage Sepsis Necrotizing enterocolitis and kernicterus
Mortality is greatly influenced by gestational age.
Tocolysis in preterm labor
At least 48 hours in order to reach maximum benefit. But bedrest and tocolysis for as long as possible with a long term goal of reaching 34-36 weeks of gestation.
Cerclage for what
Treat or prevent first trimester abortions when the cause is an incompetent cervix.
Causes of low levels of MSAFP
Chromosomal abnormalities (down and trisomy 18) Inaccurate gestational dates
Thus, for low levels of MSAFP, do US to rule out inaccurate dates. You can then move on to other causes after the dates have been confirmed by US.
Amniocentesis, when is best
CVS when is best
Cordocentesis used for what
Rapid karyotype analysis or when fetal blood dyscrasias, such as fetal anemia and Rhesus isoimmunization, are suspected.
Components of triple test
Serum estriol MSAFP bHCG
Uterine rupture vs abruptio placenta due to trauma
Uterine rupture much more likely to cause signs of hypovolemia and shock due to rapid exsanguination.
What is vasa previa
Rare condition in which fetal blood vessels traverse the membranes acrosst he lower segment of the uterus b/w the fetus and the internal cervical os.
How might vasa previa present
Painless antepartum hemorrhage assoc with rapid deterioration of the fetal heart tracing as it is fetal blood that is being lost in this condition.
Causes of premature ovarian failure
Chemo Radiation Autoimmune ovarian failure Turner syndrome Fragile X syndrome
Why is FSH more elevated than LH with ovarian failure
Slower clearance of FSH from the circulation.
Sx of premature ovarian failure
Amenorrhea Hot flashes Vaginal and breast atrophy Psychologic symptoms such as anxiety, depression, and irritability
What confirms diagnosis of premature ovarian failure
Markedly elevated FSH level in a wwoman under age 40 who has experienced >=3 months of amenorrhea --> confirms diagnosis of premature ovarian failure.
Risks of OCPs
VTE Stroke MI Breast cancer Cervical cancer Increased TGs HTN Worsening of diabetes
What cancers decrease with use of OCPs
Endometrial and ovarian cancer Benign breast disease Dysmenorrhea
OCP risk of insulin resistance
Present but very very mild. OCPs have NOT been shown to precipitate diabetes in non-diabetic patients.
Modifiable risk factors for OP
Hormonal factors such as low estrogen levels Malnutrition Decreased calcium Decreased VitD Use of certain medications such as glucocorticoids or anticonvulsants Immobility Cigarette smoking Excessive alcohol consumption (dose dependent)
Non-modifiable risk factors for OP
Female gender Advanced age Small body size Late menarche/early menopause Caucasian or asian FHx of OP
Asymptomatic chlamydia infections
50% of men 80% of women
NAA test for chlamydia and gon
Chlamydia Sens 80-92% Spec 88%
Gonorrhea Sens 98%
Treatment options for chlamydia
Single dose of azithromycin Course of doxycycline
ABO incompatibility, what pregnancy
First, because these antigens are found in the environment. But varying degress of antibody production and thus varying levels of usually minor disease.
ABO incompatibility usually manifests how
Hemolytic disease of the newborn, less severe though than RhD incompatbility.
Risk factors for endometritis
PROM >24 hours Prolonged labor >12 hours C-section Use of utrauterine pressure caths or fetal scalp electrodes
Endometritis common cause
Polymicrobial, thus treat with clinda (gram neg and anaerobes) and gent (gram positives)
Postpartum endometritis due to Chlamydia?
Uncommon, occurs many days following delivery, not in the first 48-72 hours.
Treatment of asymptomatic bacteriuria of pregnancy
Nitrofurantoin OR Amoxicillin OR First gen cephalosporin for 7 days
Young patient with heavy menses and irregular cycles
Anovulatory cycles... females in this age group have an immature hypothaalmic-pituitary-ovarian axis that may fail to produce gonadotropins in proper quantities to induce ovulation..... up to 90% of all menstrual cycles in first year after menarche may be anovulatory.
Bleeding disorders... affect menses how
Just in quantity, not in duration or cycling.
How to PCN desensitize
Incremental doses of oral PCN-V
PCN is important because it crosses the placenta. Using erythromycin would not work, e.g., for that very reason.
What is pseudocyesis
"False pregnancy," considered a form of conversion disorder in which a woman who is trying to become pregnant comes in with sx of pregnancy such as amenorrhea, enlargement of breasts and abdomen, morning sickness, weight gain, sensation of fetal movement, report of positive HCG. Pregnancy eval such as US will reveal normal endometrial stripe and HCG testin office will be negative.
Possible causes of hydronephrosis in pregnancy
Could be renal stone Could also be physiologic....
Graves disease and pregnancy
In many patients, circulating level sof TSI remain as high as 500x normal value for several months following thyroidectomy. These are IgG and thus can cross the placenta
Characteristics of neonatal thyrotoxicosis
Goiter Tachypnea Tachycardia Cardiomegaly Restlessness Diarrhea Poor weight gain in infant
Typically w/i 1-2 days following delivery.
Most common cause of abnormally increased MSAFP
Gestational age error.
Down and Edward syndrome on quadruple screen
Down - low MSAFP, low estriol, elevated bHCG, elevated inhibin A.
Edward - low MSAFP, low estriol, very low bHCG, normal inhibin A
Components of the quadruple screen
MSAFP Estriol bHCG Inhibin A
Risk factors for placenta previa
Multiparity Advanced maternal age Prior C-section Smoking Multiple gestation Prior
Relatively benign presentation of abruptio placentae
Intrauterine fetal death
Hemorrhage but with rapid deterioration of the FHT
Uterine rupture presentation
Sudden onset of intense abdominal pain, vaginal bleeding assoc with hyperventilation, agitation, and tachycardia.
The bloody show of normal labor is due to what
Tearing of small cervical veins.
Placenta previa and pelvic exam
Do not do them!
Connection between hypothyroidism and prolactin
Hypothyroidism increases TRH, which stimulates prolactin production.
Prolactin production, inhibition and stimulation
Inhibited by dopamine Stimulated by serotonin and TRH
What stimulates prolactin production
Drugs that cause high prolactin levles
Those that include dopamine antagonists: antipsychotics, TCAs, MAOIs...
How does amenorrhea work in lactating mothers
High levels of circulating prolactin ----| GnRH...
Still not reliable method of birth control. In fact 50% of nursing mothers ovulate w/i 6-12 months of delivery.
What is Human placental lactogen
Produced by placneta, has insulin antagonist effects ahd plaays an important role in nutrition of the fetus by causing maternal lipolysis and insulin resistance, thus increasing delivery of fatty acids and glucose to the fetus.
Oxytocin and lactation
Stimulates expulsion of milk from lactiferous glands.
What inhibtis gonadotropin secretion during pregnancy
Atypical antipsychotic with dopamine antagonist effects
Milk production activated by what
Sudden decrease in estogren and progesterone. Release of prolactin and oxytocin through stimulatory effect of suckling.
Lactation suppression, how to
Tight fitting bra Avoidance of nipple stimulation or manipulation Ice packs/analgesics for pain
No role of meds for the suppression of milk production. Bromocriptine has too many side effects.
Definition of abortion
Loss of pregnancy <20 weeks or Expulsion of fetus <500g.
Missed abortion, when to suspect
Loss of nausea and vomiting of early pregnancy Arrest of uterine growth...
Sx of hydatiform mole
1st trim vaginal bleeding Expulsion of villi Excessive N/V
US --> snow storm appearance, serum bHCG levels are increased.
Any hemorrhage occurring before 20th week gestation with a live fetus. Cervix closed, no passage of fetal tissue.
Vag bleeding Lower ab cramps --> radiate to back and perineum Dilated cervix
Same as incomplete abortion but incomplete evacuation of conceptus. U/S -> endometrial debris.
PCOS results from what
Abnormal GnRH secretion that stimulates pituitary to secrete excessive LH and insufficient FSH... excess LH sitmualte androgen production by ovarian theca cells resulting in hirsutism, etc. Anovulation caused by imbalance between LH and FSH production and in part insulin resistance in these patients
Progesterone produced by what
Corpus luteum following ovulation. Withdrawal of progesterone --> menses.
PCOS is ultimately an excess of what
Estrogen dose what in the ovarian cycle.
Builds up endometrium
Rupture fetal umbilical vessel sx
Antepartum hemorrhage with very characteristic fetal heart rate changes --> Tachycardia to bradycardia to a sinusoidal pattern.
Differentiates fetal from maternal blood.
Abruptio placentae type of bleeding
Dark red antepartum hemorrhage along with abdominal pain, uterine tenderness, and increase uterine tone. Bleeding is of maternal origin.
Polyhydramnios effect on mother
Result of compression of lungs, abdominal organs, and vasculature. Difficulty breathing and lower extremity edema are common.... Placental abruptiona nd PPH due to uterine atony are associated with hydramnios.
FHT --> sinusoidal pattern directly after rupture
Think Vasa previa or some other loss of fetal blood.
Maternal vital signs will be fine while the fetus exsanguinates.
Occurrence of grand mal seizures in patients with either mild or severe preeclampsia.
Management of mild preeclamspai
Methyldopa + observation + bed rest
Why is furosemide CI in pregnancy
Diuretics can inhibit the normal physiologic intravascular volume expansion that occurs as a normal function of pregnancy.
Pregnancy category C
Safety in pregnancy has not yet been established.
CCB used in pregnancy
All are class C, but Nifedipine is mor ecommonly used.
Involuntary contraciton of perineal musculature making vaginal penetration tough and painful. Underlying cause is psychological. Patients often have had strict religious upbringings in which sex was either not discussed or discussed in a negative fashion, have had trauma of childhood.
Treatment for vaginismus
Relaxation Kegel exercises Insertion of dilators, fingers, etc. to bring about desensitization.
Sex therapist referral
Hypoactive sexual desire.... and possibly vaginismus
IUGR two broad divisions
Symmetric - fetal factors, usually before 28 weeks
Asymmetric - maternal factors, usually after 28 weeks when the head has grown.
Asymmetric IUGR causes
Maternal factors: - Fetal redistribution of blood flow to vital organs, at the expense of the viscera.
Normal features of postpartum period that may initially be alarming
Low grade fever Leukocytosis Chills (intrapartum and postpartum)
Lochia rubra --> 3 to 4 days Lochia serosa then Lochia alba
Trich vaginitis vs BV
Trich - sexually transmitted infection that causes malodorous gray-green thin, frothy vag discharge, as well as vaginal and vulvar pruritus, dysuria, and dyspareunia. Pruritus and inflammation, strawberry cervix.
BV - Usually no pruritus, no inflammation.
PE in adenomyosis
Enlarged and generally symmetrical uterus
What is pelvic congestion syndrome
Varicose veins in the lower abdomen, manifesting in chronic pain which is dull ache. Larger tuerus and thicker endometrium but not outside realm of neomral.
Turner syndrome cause of infertility
Ovarian dysgenesis, restling in low estrogen levels and inability to menstraute...
Basically premature menopause, with the poor ovarian function causing FSH levels to be high due to lack of negative feedback.
Common vascular finding in Turner syndrome
False labor vs real labor
False - contractions in lower abdomen, irregular, occur at an interval that does not shorten and do not increase in intensity.
Last month --> may become rhythmic, every 10-20 minutes.
Usually do not progress, and are usually relieved by sedation.
Pain in true vs false labor
True - back and upper abdomen False - lower abdomen