364 terms

OBGYN - UWorld Facts crc

Risk factors fpr placental abruption
Prior placental abruption
Chronic hypertension
Pregnancy-induced hypertension
EtOH or tobacco use
Vascular disease sucha s DM and SLE
Most significant risk factor for placental abruption
Sustained >160/110 treat pharmacologically
Uncontrolled maternal HTN
Risk factors for placental previa
Prior c-delivery
Multiple gestation
Advanced maternal age
Uterine atony --> hemorrhage risk factors
Multiple gestation
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.
Hypogonadotrophic hypogonadism
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
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
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
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
1. Sheehan syndrome
2. Lymphocytic hypophysitis (less common)
Lymphocytic hypophysitis: present with
HEadaches, visual disturbances, and pituitary failure. Can be difficult to distinguish from pituitary neoplasm
Infiltrative disorders of the pituitary typically present with what
Diabetes insipidus
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
Aromatase deficiency
Most common cause of CAH
21 hydroxylase deficiency. Also have salt wasting...

Estrogen is still synthesized.
McCune Albright syndrome triad
Cafe au lait spots
Polyostotic fibrous dysplasia
Autonomous endocrine hyperfunction --> gonadotropin independent precocious puberty (early puberty!!)
Kallman syndrome
Hypogonadotropic hypogonadism w/ anosmia
Delayed puberty but low or absent LH and FSH levels
Galactose-1-phosphate uridyltransferase deficiency
Galactose-1-phosphate accumulation i nliver, brain, kidney --> cirrhosis, mental retardation, and Fanconi syndrome
Deficiency which causes gestational maternal virilization
Aromatase deficiency
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.
Chlamydia treatment
Doxycycline OR
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
Rosette test
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.
AFE s/sx
Abrupt onset of hypoxia, respiratory failure, cardiogenic shock, and DIC
Symptoms in endometriosis
Usually asymptomatic

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
PCOS (Stein-Leventhal)
Risk factors for breast cancer
EArly menarche
Late menopause
Cowden syndrome?
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
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
Advanced age
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
Chronically hypertensive
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
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
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
PCOS diagnosis
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
Just 50%
PCOS risks for what
Insulin resistance
Cardiovascular disease
Endometrial cancer
PCOS patients should be screened for what
Insulin insensitivity

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
Triad for a hydatidiform mole
Enlarged uterus
Markedly elevated HCG (>100,000)
Good test in the work-up for vomiting in pregnancy besides basics
HCG --> Hydatidiform mole.
Hyperemesis gravidarum diagnostic factors
Persistence of vomiting
Loss of >= 5% prepregnancy weight
Diff diagnosis for hyperemesis gravidarum
Gestational trophoblastic disease
Hepatobiliary disease

Gestational trophoblastic disease
Hepatobiliary disease
Suspected PCOS in whom
Menstrual irregularities +
Evidence of hyperandrogenism
Two things needed for PCOS
Menstrual irregularities
Evidence of hyperandrogenism
PCOS risk for what
Endometrial cancer

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.
PID criteria diagnosis
Fever>38 C
Elevated ESR
Purulent cervical discharge
Adnexal tenderness
Cervical motion tenderness
Lower abdominal tenderness
PID causes
N. gonorrhea
C. trachomatis
Genital mycoplasmas
Regimens for PID, hospitalized
Regimens for PID, outpatient
Cefoxitin + Probenecid + Doxy
Ceftriaxone + Doxycycline
Maternal opioid abuse
Withdrawal symptoms in the infants following birth --> irritability, tremors, vomiting, diarrhea, and salivation. Long-term CNS deficits in these infants and an increased risk of SIDS
GBS in infants

w/i first seven days of life
Uncontrolled maternal DM
Fetal macrosomia
Birth injuries
Congenital malformations
Respiratory distress
Cardiomyopathy among other possible findings
Fetal alcohol syndrome, typical findings
Growth restriction
Midfacial hypoplasia
Smooth philtrum
Short palpebral fissures
Thin upper lip
CNS abnormalities
Emergency contraception

Effective up to 120 hours post intercourse, but effectiveness is greater the earlier the medication is administered.
Effectiveness of the plan B
7 out of 8 women who would have otherwise become pregnant from intercourse.
Depo provera, what is this
IM medroxyprogesterone.
2nd trimester abortifacient
Prostaglandin E2 suppositories
Diff dx for hyperemesis gravidarum
Gestational trophoblastic disease
Hepatobiliary disease
PCOS deficient in what
Progesterone secretion, thus they have constant and unbalanced mitogenic stimulation of the endometrium by estrogens leading to endometrial hyperplasia
Fetal alcohol syndrome s/sx
Facial dysmorphology: midfacial hypoplasia, micrognathia, flattened (smooth) philtrum, microphthalmia, short palpebral fissures, thin upper lip
CNS damage: irritability, ADHD, learning disabilities, frank mental retardation
When does GBS typically occur
W/i first seven days of life. But then there's also late onset...
Symptoms of withdrawal in an infant

Long term CNS deficits wtih increased risk of SIDS
Uncontrolled diabetes maternal-fetal effects
Birth injuries
Congenital malformations
Respiratory distress
Window for emergency contraception
120 hours
Depoprovera is what
Medroxyprogesterone q3 months
Breech presentations <37 weeks, usual fates?
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.
Mullerian agenesis
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
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
Testicular hypoplasia
Risk factor for VAGINAL scc?
Risk factors for endometrial cancer
Chronic unopposed estrogen use (PCOS??)
Late menopause
Diabetes mellitus
Chronic TAMOXIFEN use
Risk factors for ovarian cancer
Lack of prior oral contraceptive use
PE findigns in adenomyosis
Enlarged but generally symmetrical uterus
Differential diagnoses for adenomyosis
Endometrial carcinoma

All can present with dysmenorrhea, menorrahgia and a large sized uterus

>35? Endometrial curettage to r/o endometrial carcinoma.
Endometritis presentation
Enlarged and tender uterus
Foul smelling vaginal discharge

Usually occurs after a septic abortion or in the postpartum period (puerperal fever)
Who gets adenomyosis typically?
Multiparous women >40 yo. Typically presents with dysmenorrhea and menorrhagia. PE reveals enlarged and generally symmetrical uterus...

DDx; fibroids, but this is irregularly shaped uterus.
Indications for GBS prophylaxis when GBS status is unknown
Delivery<37 weeks
Duration of membrane rupture >=18 weeks
GBS bacteriuria in any concentration during current pregnancy
PHx of previous delivery of infant with GBS sepsis
GBS prophylaxis
PCN during labor
Alternatives: ampicilling, cefazolin, clindamycin, or vancomycin...
Tocolysis in the setting of PPROM
Short term, so that glucocorticoids can be given to promote fetal lung maturity.. usually <32 weeks gestation, often 32-34, but never >=35 weeks
When is injection of dye into the uterus helpful
Early early PPROM, when ROM is difficult to confirm. PPROM early on may commit pregnant woman to long term bedrest.
Antenatal corticosteroids, when typically
<32 weeks gestation.
Prevents neonatal RDS, necrotizing enterocolitis, neonatal intraventricular hemorrhage, and neonatal death....

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
GnRH agonist
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.
Medroxyprogesterone acetate
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)
GDM pregnancy risks
Congenital malformations
Preterm birth
Meconium aspiration,
Ideal range of FBG
GDM effectson the fetus
Hyperviscosity due to polycythemia
Respiratory difficulties
Why polycythemia in infant born to diabetic mother?
Fetal hypoxia which occurs in face of increased basal metabolic rate induced by hyperglycemia. Increased EPO production by the fetus increases RBC mass and oxygen carrying capacity of the blood.
Is GDM assoc with MR
Inevitable abortion characterized by what?
Vaginal bleeding, fluid discharge
Lower abdominal cramps
Dilated cervix through which POCs can occasionally be visualized.

U/S --> ruptured or collapsed gestational sac and absence of fetal cardiac motion.
Threatened abortion?
Any hemorrhage occurring before 20th week gestation with a live fetus... Cervix closed, no passage of fetal tissue. Mild lower abdominal pain may be noted. FHR active on U/S.
Molar pregnancy characterization
1st trimester vaginal hemorrhage assoc with expulsion of vesicles (villi), excessive nausea and vomiting, and uterine size greater than dates.

U/S --> snow storm appearance with no FHR or identifiable fetal structures, and bHCG markedly increased.
Missed abortion
Fetus expires in utero, but the POCs are not discharged from the uterus spontaneously. Patients present with loss of pregnancy sx and no continued increase in uterine size.
US --> retained fetus, no FHR
Missed abortion
Complete abortion
Ab pain and cramping
Vaginal bleeding and passage of tissue from the uterus, on exam: cervix is closed and US demonstrates an empty uterus.
Sx of trich
Green, frothy, foul smelling vaginal discharge
Urinary symptosm or dyspareunia as well

Some women are completely asymptomatic!
Also Candida vaginitis and BV can present similarly.
Treatment for Trichomonas
Metronidazole for person and partner. Oral! Affected males are usually asymptomatic.
When should pregnant women be syphilis treated
First prenatal visit (RPR or VDRL).
Then confirm with Fluorescent Treponemal Antibody Absorption test (FTA-ABS).
USPSTF recommendations for chlamydia testing
All women 24 and younger
Hx of STDS,new or multiple partners
Hypogonadotropic hypogonadism due to what
Severe life stressors
Eating disorders
Excessive exercise...

Insufficient pulses of GnRH from hypothalamus causes pituitary LH and FSH production to decrease.
Continuous GnRH therapy for whom
Children with precocious puberty (GnRH dependent)
Men and women with sex hormone-dependent tumors.
Severe preeclampsia definition
Presence of one or more of:
- Oliguria
- AMS, headache, scotoma, blurred vision
- PulmEdema, cyanosis
- Epigastric or cyanosis
- Significant thrombocytopenia
- Microangiopathic hemolysis
- Altered LFTs
- Elevated serum creatinine
- IUGR or oligo
Mech of eclamptic seizures
Cerebral vasospasm --> cerebral hypoxemia and generalized tonic clonic seizures. Can be thought of as a specialized subset of hypertensive encephalopathy that occurs in the setting of preeclampsia.
Eclampsia according to delivery time
25% before labor
50% during labor
25% following delivery
What usually heralds the occurence of seizures in patients with preeclampsia
Increased reflex irritability
First priority in eclampsia
Two large bore needles
Magnesium sulfate to prevent further seizures
Suspect chorioamnionitis in whom
PPROM, or prolonged premature rupture of membranes
Maternal tachycardia (>100)
Fetal tachycardia (>160)
Maternal leukocytosis (>15k)
Uterine tenderness or foul smelling amniotic fluid
Signs of abruptio placentae
Ab or back pain
Uterine tenderness
+/- bleeding
Fetal distress
Trich with obstetric complications?
Not assoc except possible assoc with early labor... maybe...
Interventions for chorioamnionitis
Broad spectrum antibiotics
Induction of labor (oxytocin??)

If fetal distress --> consider caesarian delivery.
Single most useful parameter for predicting fetal weight?
Abdominal girth - affected in both symmetric and asymmetric fetal growth restriction
Symmetric vs asymmetric fetal growth restriction
Symmetrical - usually insult <28 weeks gestation, and growth of both head and body is deficient. TORCH or genetic stuff

Asymmetric - >28 weeks, results from other thungs... insults after this time.
When is FGR suspected
Fundal height at least 3cm less than the actual gestational agein weeks, confirmed via US
Post-term pregnancy problems
Any pregnancy at or beyond 42 weeks --> BIW U/S required to evluate for oligohydramnioas b/c amniotic fluid can become drastically reduced within 24-48 hours....
Oligohydramnios definiotn
No vertical amniotic fluid pocket >2cm
AFI of 5cm or less.
Polyhydramnios associated with what congenital fetal malformations
GI tract
Risk factors for abruptio placentae
Uncontrolled maternal hypertension
Maternal cocaine use
History of prior episodes of placental abruption
Risk factors for placenta previa
Advancing maternal age
Multiple gestations
Prior cesarian section
Preeclampsia risk factors
Extremes of maternal age
Renal diseases
Collagen vascular diseases
Baseline uncontrolled maternal hypertension
FHx of preeclampsia
Surgical neurogenic bladder treatment
Intermittent cath-ing
Earliest sign of mag toxicity
Depressed DTRs

Mag causes CNS depresion by blocking neuromuscular transmission. Regular exam with DTRs is mandated.
Second sign of mag toxicity
Respiratory depression
Definition of threatened abortion
Any hemorrhage from uterine cavity occurring before the 20th week of gestation with a live fetus.
Inevitable abortion
Vaginal bleeding, lower abdominal cramps, dilated cervix. US --> ruptured or collapsed gestational sac with absence of fetal cardiac motion.
Semen analysis in infertility, when should it occur
Early in the evaluation of the infertile couple. Accounts for 20-30% of infertility causes. And a relatively simple test.
How to evaluate anovulation as a potential cause of infertility
Basal body temp
Serum progesterone measurement in mid-luteal phase.
Endometrial sampling
Normal fibrinogen levels
Management of inevitable or incomplete abortions
Hospitalization, observation for sepsis, DIC, and extensive hemorrhage
IV fluids
Suction curettage
RhoGAM administration
When is induction of labor used in a missed abortion
>16 weeks
Repeat Pap smear in 6-12 months
HPV testing in 12 months

Either of these are weird? Colposcopy. If persistent colposcopy changes --> diagnostic excisional procedure to rule out high grade lesions.
Risks of CNC orLEEP
Cervical stenosis or incompetence
Most common clinical finding of abruptio placentae
Dark, red, third trimester vaginal bleeding - 80% of cases. Thus can be concealed in 20% of cases --> only sx may be uterine tenderness, hyperactivity, and increased uterine tone.
US for r/o abruptions
May only detect 25% of all placental abruptions
Maneuver where you push baby back in
Zavanelli maneuver
Serious complications of abruptio placentae
What is the role of US in evaluation of antepartum hemorrhage
Primarily to rule out placenta previa.

Previa - uterus is NONTENDER.
Risk factors for abruptio placentae
Maternal hypertension and preeclampsia
Placental abruption in a previous pregnancy
Rapid decompression of a hydramnios
Short umbilical cord
Tobacco use and cocaine abuse
Folate deficiency
Vasa previa
Rare --> fetal blood vessels traverse the fetal membranes across the lower segment of the uterus between the fetus and the internal cervical os..

Presents wtih painless antepartum/intrapartum hemorrhage assoc with rapid deterioration of the fetal heart tracing.
What precedes uterine rupture
C-section usually
Preceded by agitation, hyperventilation, tachycardia. Rupture is rare and most often a problem during active labor, not during the antepartum period.
Painful third trimester vaginal bleeding, normal ultrasound
Placental abruption
Risk factors for cervical insufficiency
Prior gyn surgery esp LEEP or cone biopsy, elective abortion
Prior ob trauma
Multiple gestation
Mullerian anomalies and a history of preterm birth or a second trimester pregnancy loss
Risk factors for uterine rupture
Previous c-section or myomectomy
Advanced maternal age
Risk factors for polyhydramnios
Fetal malformations
Genetic disorders
Multiple gestation
Fetal anemia
Risk factors for abruptio placentae
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
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
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
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
24-34 weeks
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
Cleft lip and palate
Digital hypoplasia
Developmental delay
Congenital syphilis signs/sx
Skin lesions

Later signs!!
Interstitial keratitis
Hutchinson teeth
Saddle nose
Saber shins
CNS involvement
Like FHS: midfacial hypoplasia, microcephaly, stunted growth

CNS damage, which may manifest as hyperactivity, MR, or learning diasbility..

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
Intraventricular hemorrhage
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
16-20 weeks
CVS when is best
10-12 weeks
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
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
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
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
Breast cancer
Cervical cancer
Increased TGs
Worsening of diabetes
What cancers decrease with use of OCPs
Endometrial and ovarian cancer
Benign breast disease
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
Decreased calcium
Decreased VitD
Use of certain medications such as glucocorticoids or anticonvulsants
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
Sens 80-92%
Spec 88%

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
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
First gen cephalosporin for 7 days
Risks of asymptomatic bacteriuria in pregnancy
Cystitis, pyelo
Low birth weight
Increased perinatal mortality
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
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
Inhibin A
Risk factors for placenta previa
Advanced maternal age
Prior C-section
Multiple gestation
Relatively benign presentation of abruptio placentae
Intrauterine fetal death
Hemorrhage but with rapid deterioration of the FHT
Vasa previa
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
Placental estrogens
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.
Threatened abortion
Any hemorrhage occurring before 20th week gestation with a live fetus. Cervix closed, no passage of fetal tissue.
Inevitabel abortion
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.
Apt test
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.
Mild preeclampsia
HTN >140/90
Proteinuria >0.3g/24h
Severe preeclampsia
Elevated liver enzymes
Possibly pulmonary edema
Transient HTN to preeclampsia
Protein crosses 300mg / day threshold
Eclampsia defined as what
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
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.

- Maternal HTN
- Preeclampsia
- Uterine anomalies
- Maternal antiphospholipid syndrome
- Collagen vascular disease
- Maternal cig smoking
Symmetric IUGR causes
Usually fetal:
- Chromosomal abnormalities
- Congenital anomalies
- Congenital infections --> TORCH
Most accurate estimationsof fetal dates
US in first trimester
Renal plasma flow during pregnancy.
Increase in renal function begins early in first trimester, progresses gradually until reaching 40-50% above non-pregnant state by mid-pregnancy, and remains unchanged until term.
Steroid acne characterized by what
Monomorphous pink papules and absence of comedones.
What may indicate an imminent rupture
Premenopausal women with simple or complex endometrial hyperplasia w/o atypia
Typically they respond to Cyclic progestins.... Risk of progression to endometrial cancer is low <3%.

Also need repeat biopsy in 3-6 months.
Eval of primary amenorrhea...
Uterus absent/present

Absent --> Karyotype, serum testosterone

Present --> FSH... increased --> karyotype, decreased --> cranial MRI
What does FSH determine in the eval of primary amenorrhea
Central vs gonadal problems
GnRH stim test good for what
Eval of precocious puberty
Major source of estrogen in menopausal women
Peripheral conversion of adrenal androgens by aromatase in adipose tissue.
Breast engorgement treatment
Cool compresses, acetaminophen, NSAIDs used for symptom control.
Clomiphene what is this
Estrogen analog (SERM) that improves GnRH release and FSH release thus improving chances of ovulation.
Luteal phase
post ovulation, progesterone primary peak, estrogen secondary peak.

Defects - progesterone replacement.
Ways to improve ovulation in PCOS patients
Treatment for hyperprolactin
Dopamine agonists, Bromocriptine and something else.
Treatment oral for yeast infections
Oral fluconazole
Treatment of BV in pregnancy
Actually same as that for BV normally, so oral metronidazole 500mg BID x 7 days.

Vaginal metro or clinda are alternatives.
Candidal infections during pregnancy
Fluconazole is safe
Macrolides that are safe in pregnancy
Azithromycin. NOT Erythromycin because it may cause acute cholestatic hepatitis.
Three D's of endometriosis

Other features - pelvic pain, infertility.
Treatment for endometriosis
Estrogen and progestin
GnRH analogs - leuprolide
Somatization disorder
Four pain symptoms
Two GI symptoms
One sexual symptom
One pseudoneurologic symptom
Medical causes of dyspareunia
Local infections
Vulvar or vaginal growths
Estrogen deficiency
Arrest of descent definition
Lack of change (fetal presenting part) in 2 hours for primigravid patients
1 hour for multigravid

Add an extra hour if an epidural is in place.
Second phase of labor
Full dilation to birth of baby
How can the causes of protraction and arrest of descent be broken down
Findings suggestive of cephalopelvic disproportion
Increased molding of fetal skull
Prominent ischial spines
When can forceps be used
Second stage of labor (after full dilation)
Zavanelli manuever
Last resort in cause of shoulder dystocia
Consists of pushing baby back into the uterine cavity followed by a ceasarian section.
Problems in power with arrest of descent
Hypotonic contractions
Epidural anesthesia
Cephalopelvic disproportion
Normal features of postpartum period that may initially be alarming
Low grade fever
Chills (intrapartum and postpartum)
Lochia characteristics
Lochia rubra
--> 3 to 4 days
Lochia serosa
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
Aortic coarctation
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