423 terms

OBGYN - Case Files Notes crc

Excessive menstrual flow
Features of menstrual history
Age of menarche
Character of menstrual cycles (time)
Quantity (length)
Irregular and heavy menses
ROS in pregnant women
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
Blood type
Rubella titer
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
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
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
Spinal cord injuries
Lower motor neuropathies
Urethral edema following pelvic surgery
Cystometric evaluation is used to distinguish between what
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
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
Addressing common diseases
Thyroid function testing parameters
At what point are pap smears not cost effective
Fasting blood sugar testing parameters
q3y at age 45
Women <20, most common cause of mortality
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?
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
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
"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
When a labor abnormality is diagnosed, what should be assessed
Powers problem with labor

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
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
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
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
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
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
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
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
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
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
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.
Maternal/neonatal complication of shoulder dystocia
Maternal - PPH
Neonatal - Brachial plexus injury such as an Erb palsy
Risk factors for shoulder dystocia
Operative vaginal delivery
Second stage of labor upper limits
Multiparous - 1 hour, 2 hours with epidural.
What is the "turtle sign"?
REtraction of the fetal head back toward the maternal introitus, shoulder dystocia.
Shoulder dystocia
Inability of fetal shoulders to deliver spontaneously usually due to impaction of the anterior shoulder behind the maternal symphysis pubis.
Fetal maneuvers for shoulder dystocia
Wood corkscrew (progressively rotating the posterior shoulder in 180degrees in a corkscrew fashion)
Delivery of posterior arm first
Zavanelli --> Last ditch.
What does the McRoberts maneuver actually do
Anterior rotation of the symphysis pubis.
Straightens the sacrum relative to the lumbar spine.
Rationale of suprapubic pressure for shoulder dystocia
Moves fetal shoulders from AP to an oblique plane, allowing the shoulder to slip out from under the symphysis pubis.
Dystocia complications of hydrocephalus
HEad itself may have a difficult time passing through the pelvis.
Opposite of prolonged labor
Precipitous labor
What arm should be delivered in shoulder dystocia
Posterior one. This reduces shoulder girdle diameter from shoulder-to-shoulder to shoulder-to-axilla
Manifestation of ureteral injury after hysterectomy
Almost identical to pyelonephritis. Flank tenderness, fever, CVA tenderness.... with a recent history of hysterectomy. Also r/o wound infection.
Evaluation of ureteral injury after hysterectomy
IV pyelogram
CT scan of ab with IV contrast
Risk factors for ureteral injury in hysterectomies
Extensive adhesions
Residual ovaries
Interligamentous leiomyomata

Any gyn procedure can do it!!!
Most common location for ureteral injury
AT cardinal ligament, where the yreter is only 2-3 cm lateral to the cervix.

Other locations:
- Pelvic brim which occurs during ligation of infundibulopelvic ligament
- At point which ureter enters the bladder (Ant to vagina, when the vag cuff is ligated at the end).
Possible ureter injury, and IVP shows possible obstruction. Next steps?
Antibiotic administration
Cystoscopy to attempt retrograde stent passage. Done in the hope that the ureter is kinked and not occluded... relief of obstruction paramount in preventing renal damage.

Should weigh initial ureter repair vs percutaneous nephrostomy with lateral ureteral repair.
MGmt of perioperative bladder lacerations
Dome --> can be sutured
Trigone area --> may need ureteral stent placement to prevent ureteral stricture.
Bladder perforation injury presentation
Gross hematuria
Tenderness in suprapubic region
Difficulty in voiding
N/V --> urine leaked into abdominal cavity will cause irritation to intestines
Blood supply to ureters
Receives blood supply from various arteries along its course, and flows along its adventitial sheath.

Thus, overdissection of ureters can itself cause ureteral injury
Imaging test of choice for patient with suspected ureteral injury
IV pyelogram
Postmenopausal bleeding, first step in eval
Concern for endometrial cancer, thus an endometrial biopsy. Initial endometrial sampling or aspiration can be done in office... blind sampling has 90-95% sensitivity for detecting cancer. This is the same as a biopsy.
Risk factors for endometrial cancer
Prior anovulation (irregular menses)
Late menopause
Early menarche
Unopposed estrogen therapy
Estrogen secreting ovarian tumors

Primarily have to do with unopposed estrogen exposure to the endometrium.
Causes for PMB
Endometrial cancer
Atrophic endometrium
Endometrial polyps
Most common cause of postmenopausal bleeding
Atrophic endometrium, in which the tissue of the endometrium or vagina is friable due to low estrogen levels. Also vaginitis

But 20% of PMB not on hormonal therapy but complaining of vaginal bleeding will have an endometrial carcinoma. And this can exist with that other stuff, so it always needs to be r/o.
Normal thickness of the endometrial stripe in a postmenopausal female
Thickness greater than 5mm is abnormal....
Risk of complex hyperplasia with atypia progressing to cancer
30-50% of cases
Possible methods for assessment of the endometrium?
Endometrial sampling
Vaginal sonography
PMB with unrevealing endometrial sampling but persistent bleeding as well as numerous risk factors
Hysteroscopy. This can reveal smaller lesions that may be missed by the office endometrial sampling device. Additionally, endometrial polyps can be identified by hysteroscopy.
Most common female genital tract malignancy
Endometrial cancer. If it occurs in atypical patients, they seem to be more aggressive.
How to stage endometrial cancer
- Omentectomy
- LN sampling
- Peritoneal washing
Biggest risk factor for endometrial cancer
Ingestion of unopposed estrogen
OCP effects on endometrial cancer
Decreases risk due to progestin prevention of the endometrium from becoming hyperprolific.
Smoking risk of endometrial cancer?
Lower estrogenic state --> less of a risk.
Atypical glandular cells on pap may indicate what
Endocervical or endometrial cancer
Progesterone and endometrial cancer
Progesterone is effective in shedding endometrial lining, but not at inhibiting cellular proliferation once endometrial cells becoem complex and atypical.
Postcoital antepartum spotting
Placenta previa
Definition of low lying placenta
Edge of the placenta is within 2-3 cm of the internal cervical os.
Two most common causes of significant antepartum bleeding
Placental abruption
Placenta previa
Antepartum hemorrhage, firs tstep
First, r/o previa!! By U/S. Speculum or digitial examination may induce bleeding.
Natural history of placenta previa
First instance of bleeding does not cause sufficient enough concern for delivery. Often, the second or third episode of bleeding forces delivery.
Risk to mom differences with bleeding from previa vs bleeding from abruption
Bleeding from a previa rarely leads to coagulopathy
Previa at around 36-37 weeks, steps in eval
Amniocentesis to assess for fetal lung maturity.... if mature, then delivery possibly will be scheduled!!
Placenta previa often goes hand in hand with what other placental implantation problem
Placenta accreta.
Risk factors for previa!!!
Grand multiparity
Prior Cesarian delivery
Prior uterine curettage
Prev placenta previa
Multiple gestation
How does the cervix look in a previa
May be very well vascularized.
Marginal or low lying previa at 22 weeks, what should be done
35 week repeat to assess for transmigration of the placenta.
When are placenta percreta and increta diagnosed
Cesarian section
Not radiographically...
Placenta Previa + history of C-sections, watch out for what
Complications of a placental abruption
Fetal to maternal bleeding
Preterm delivery
One test that is diagnostic of abruption
None exists, even U/S can be normal.
Couvelaire tuerus
Blood from abruption seeps into the uterine muscle and causes reddish discoloration. Uterine atony and PPH after delivery may occur
Postdelivery signs of abruption
Blood clot adherent to placenta at delivery.
How often is coagulopathy assoc with abruption
In abruption severe enough to cause fetal death, coagulopathy is foundin 1/3 or more cases.
Fibrinogen levels in pregnant person indicative of possible coagulopathy
100-150 (low normal)
What is helpful in assessing an abruption
Serial hemoglobin levels, following fundal height, assessment of FHT

Some practitioners recommend testing for fetal erythrocytes in maternal blood.
Test for fetal erythrocytes in maternnal blood
Kleihauer-Betke test, which takes advantage of different solubilities of maternal versus fetal hemoglobin.
Mgmt of abruption
Usually delivery..... Unless "chronic abruption" in premature fetus.
Mgmt of women who have fetal death due to abruption
Vaginal delivery, while giving blood products and IV fluids to maintain Hct >25-30%, and UOP of at least 30ml/hr. These women generally have very rapid labors.

Many will manifest preeclampsia-like illness following volume replacement, requiring use of Mag
Why is US bad at detecting abruption
Fresh blood clot behind the placenta has same sonographic texture as the placenta itself.
Risk factors for placental abruption
Uterine leiomyomata (esp submucosal type)
Short umbilical cord
Uteroplacental insufficiency
Preterm Premature ROM
Most common presenting symptom of invasive cervical cancer
Abnormal vaginal bleeding
Sexually active women, postcoital spotting is common.
Mean age of presentation for cervical cancer
51 yo
Risk factors for cervical cancer
Cigarette smoking
Hx of STDs (esp syphilis)
Early age of coitus
Multiple sex partners
HIV infection
Early childbearing
Low socioeconomic status
HPV what kind of virus
RADICAL hysterectomy
Removal of uterus, cervix, and also supportive ligaments such as the cardinal ligament, uterosacral, and proximal vagina.
What is radiation brachytherapy
Radioactive implants placed near the tumor bed.
What is radiation teletherapy
External beam radiation where the target is some distance from the radiation source.
HPV vaccine approved for what ages
9-26 yo
Quadrivalent vaccine covers what
16,18 --> assoc with 50% of cervical cancer and dysplasia.
Postcoital spotting no pregnancy
Cervical dysplasia or cancer should be suspected...
Where does most cervical cancer arise
Squamocolumnar junction (SCJ)
Rupture of membranes --> FHR that increases, then decreases, then has a sinusoidal appearance.
Rupture of vasa previa, which is due to velamentous cord insertion.
What is velamentous cord insertion
Umbilical vessels separate before reaching the placenta, procted only by a thin fold of amnion, instead of cord or placenta itself.
What is chorionicity
Number of placentas in a twin or higher order gestation....
What medication is associated with an increased rate of twining
Recent history of OCPs w/i 3 months. Possibly due to the slowing of fallopian tube mobility.
Monochorionic vs dichorionic
Monochorionic much higher rates of spontaneous abortion.... luckily mono mono only occurs in 1%
Dizygotic twinning with maternal age
Increased incidence, peaks at 37 weeks.
Also increased incidence if mom is of a dizygotic twin.
BP in multifetal gestation
Lower than singleton preg at 20 weeks, but higher at delivery.
What increases survival of vasa previa
Prenatal diagnosis, increases it from 44-97%. The catch is that prenatal diagnosis of this condition is difficult. Thus you have risk factors.
Risk factors for vasa previa
Bilobed, succenturiate-lobed, or low lying placenta
Multifetal pregnancy
Pregnancy resulting from in vitro

Women with these findings --> color Doppler US.
Vasa previa management
Planned C-delivery shuld take place before rupture of membranes around 35-36 weeks gestation. Digital exam is contraindicated!!!
What can differentiate fetal from maternal blood
Apt test -
Kleihauer Betke test - different fetal solubilities in acid.......

Both are kind of the same...
Fetal blood volume
250-500 cc
Only a very thin membrane in between fetusus, at around 15 weeks or so
Probably Monochorionic, diamnionic... This is because only amnionic membranes between the two.... unlike the other one which is chorionic and amnionici
Preeclampsia with tanking oxsats, twin delivery.
Pulmonary edema due to reeclampsias as well as increased plasma volume due to multiple gestations....

Treat with IV furosemide, as well as mag sulfate, and plan for delivery.

CXR is helpful, would demonstrate infiltrates.
Why avoid corticosteroids in multiple gestations, or at least think twice
Increased risk of pulmonary edema.
Twin gestation without dividing membrane risk
Cord entanglement --> stillbirth.
Neuro effects of severe preeclamspai
Vision changes
Renal - preeclamspai
Decreased GFR
Pulm - preeclampsia
Pulmonary edema
Hematologic and vascular effects of preeclampsia
Microangiopathic anemia
Severe HTN (>160/110)
Fetal effects of preeclampsia
Decreased uterine perfusion --> Late decels
Hepatic effects of preeclampsia
Increased LFTs
Subcapsular hematoma
Hepatic rupture
Lab tests for preeclamspia
urine tests, including 24 h protein
LDH --> increaesd in hemolysis
Uric acid test

Also consider a BPP
Components of the BPP
Fetal activity
Fetal tone
Fetal breathing or hiccups
Important to monitor what in mag dosing
Excreted by the kidneys, so urine output.
Also: Respiratory depression, dyspnea (side effect of mag sulfate is pulmonary edema), and abolition of the DTRs --> First sign of toxic effects
First sign of mag toxicity
Abolition of the DTRs
How to control the severe HTN of preeclampsia
Preeclamptic woman delivers, when is mag sulfate d/c'd
24 hours postpartum

F/u in 1-2 weeks to check BPs and proteinuria
Why is protein >5g such an important criterion for severe preeclampsia
Signifies significant renal damage, and if allowed to continue, end organ damage with renal iniffucient may ensure, including oliguria.
Criteria for severe preeclampsia
>5g/24 h urine protein
Severe h/a
RUQ or epigastric pain
vision changes
Most common cause of maternal death in the setting of eclampsia
Intracerebral hemorrhage.

Greatest risk for eclampsia --> just prior to delivery, during labor, and within first 24h pp.
Mgmt of mild preeclampsia in a preterm patient, do you treat the HTN?
No... expectant management.. until severe criteria show up, or term gestation is reached.
First sign of mag tox
Loss of DTRs
Management of what looks to be a small breast mass in a young woman
Think fibroadenoma, and biopsy the mass via FNA or core needle biopsy...

Pretty much any three dimensional dominant mass needs a biopsy. Also, the greater the risk for breast cncer, the more tissue is needed during your biopsy. And that's when you distinguish between FNA (aspiration of loose cells), core needle, and excisional.
General approach for WWE
Cancer screening
Assessment and prevention for common disorders.
Fibroadenomas vs fibrocystic changes
Fibroadenomas do not change with the menstrual cycle, although fibrocystic changes do.
Clinical presentation of fibrocystic changes
Cyclic, painful, engorged breasts mroe pronounced just before menstruation, occasionally may have serous or green breast discharge.

Usually can be distinguished from a dominant mass... thus requires rechecking.
Treatment for fibrocystic breast changes
Decreased caffeine
Adding NSAIDs, tight fitting bra, OCPs, oral progestin therapy.

W/ severe cases, danazol, or even mastectomy.
What is a concordant triple assessment mean
When the Clinical exam, Imaging (US or mammography), and histology are all in agreement. Histo can be done with either FNA or core needle. High reliability for diagnostic result.

Nonconcordance --> Usually indicates obtaining more tissue...
Most common cause of bloody nipple discharge unilateral
Intraductal papilloma, which are typically small benign tumors that grow in the milk ducts
What ages get Intraductal Papillomas
35-55 age group. Causes and risk factors are unknown.
Second most common cause of bloody nipple discharge
Galactocele presenation
Painful,engorged breast. Galactocele is a mammary gland tumor that is cystic in nature and contains milk or milky fluid.They typically occur when there is any sort of obstruction of milk flow in the lactating breast.
Severe cases of fibrocystic breast disease
Best way to image breast mass of a woman <30 yo
Ultrasound, due too dense fibrocystic changes that interfere with mammographic interpretation. US can also distinguish between a solid vs cystic mass, and sometime can suggest a fibroadenoma. Nevertheless, tissue should be obtained
"Red tender indurated breast" in a nonlactating woman. What must be ruled out?
Inflammatory breast cancer. Biopsy is critical. No matter how much it looks like a simple infection.

This cancer is aggresive in nature, and the skin changes occur due to cancer cells within the subdermal lymph channels. Immediate diagnosis and therapy are crucial, whereas delay with various antibitoics would be detrimental. This also occurs more in younge rpatients, but women of any age can be affected.
Five basic things to consider in infertility
Male factor
Peritoneal factor --> endometriosis
Evidence for regular ovulation
Regular monthly menses
Biphasic basal body temperature
How to assess normal tubes
How to assess cervical factor
Hx of cervical procedures...
Three D's of endometriosis
Infertility affects how many couples
10-15% of couples in the reproductive age group
Normal fecundability
Probability of achieving a pregnancy within one menstrual cycle. 20-25% for a normal couple. On this basis 90% of couples should conceive within 12 months.
Five main causes of infertility
1. Ovulatory factors - 30-40%
2. Uterine factors - hysterosalpingogram within 6-10 days of the cycle, possible hysteroscopy --> recurrent pregnancy losses!!
3. Tubal factor - PID or something. Hysterosalpinogram, but lapaproscopy is gold standard.
4. Male factor
5. Peritoneal factor
What is the easiest and least expensive way to assess ovulation
Basal body temperature chart - orally, wakes up, eats, or drinks beforehand.
Why does basal body temp rise after ovulation, and by how much does it rise
0.5F due to the release of progesterone, which is a thermogenic hormone.
Besides regular menses and BBT, what are other ways of assessing ovulation
Midluteal (day 21) progesterone
LH surge with urine test kits - ovulation occurs predictably 36h after onset of LH surge

Other tests more invasive:
- Endometrial biopsy showing secretory tissue
- US showing decrease in follicular size and presence of fluid in the cul-de-sac, suggesting ovulation.
Normal male factor
Volume > 2ml
Sperm concentration > 20 mil/ml
Motility >50%
Morphology >30% or >4% normal forms

Abstinence period of 2-3 days prior to semen collection is recommended. Repeat abnormal test after 2-3 months.
What is Peritoneal factor
aka endometriosis, may explain infertility even if the patient does not complain of the 3 D's (dyspareunia, dysmenorrhea, dyschezia). Mechanism of infertility is not completely understood.

Dx/Tx: laparoscopy
How to assess cervical factor
May be suspected with thick, viscid mucus before ovulation. Intratuerine insemination may help
History features that may indicate a deficiency of male factor
Mumps in past medical history
Tubal disorder causing infertility, what measures
Intrauterine insemination is good for treating what factor in infertility specifically
Cervical factor (e.g. thick viscid cervical mucus before ovulation). This procedure bypasses unfavorable cervix by using a catheter to inject washed sperm beyond that barrier.
Progesterone assay
Good to assess for if ovulation occurs.
Most likely ovarian cyst in a young female
Dermoid cyst
Ovarian torsion
Acute onset of colicky, lower abdominal pain, and N/V. GI complaints are common with torsion.
Treatment of ovarian torsion in a pregnant woman vs a nonpregnant
Pregnant women do not have the option of laparoscopy.
When do pregnant women usually present with ovarian torsion if they were to
14weeks, when the uterus rises above the pelvic brim
Postpartum, when the uterus rapidly involutes
When does the uterus rise above the pelvic brim
14 weeks
Common causes of abdominal pain in pregnant women
Appendicitis (any trimester)
Acute chole (after first trimester)
Ovarian torsion (14 weeks or pp)
Abruptio placenta (2nd and 3rd trimesters)
Ectopic (1st)
What trimester has the worst effects of delaying an appendicitis diagnosis
3rd --> most maternal morbidity and mortality and also perinatal problems includin gpreterm labor and abortion.
Location of pregnant appendicits pain
Not typically in RLQ!!!

Instead, superior and lateral to McBurney point,due to the effect of the enlarged uterus pushing on the appendix to move it upward and outward toward the flank. May sort of mimic pyelonephritis...
Diagnosis of pregnant appendicitis is made how
Clinically... Because of morbidity of missed diagnosis, beterto err on the side of overdiagnosing
Simple biliary colic in pregnancy, how is this treated
Low fat diet
Surgery for what biliary disease
Biliary obstruction
Most frequent complication of a benign ovarian cyst
Ovarian torsion1!! It is also the most serious.
Risk factors for abruption of placenta
Previous abruption
Hypertensive disease in pregnancy
Cocaine use
Presentation of abruptio placenta
Vaginal bleeding with persistent crampy midline uterine tenderness and at times abnromal FHTRACINGs.

Ultrasound not very reliable.
Leading cause of maternal mortality in 1st and 2nd trimesters
Ectopic pregnancy.
Ectopic pregnancy presentation
Amenorrhea with some vaginal spotting
Lower abdominal and pelvic pain. Pain is typically sharp and tearing and may be assoc with nausea and vomiting.
Diagnose ectopic
Transvaginal US
Serum hCG
Most common cause of pancreatitis in pregnancy or otherwise
The growing uterus pushes the appendix where
Superior and lateral, thus the pain is shifted in those vectors.
Treatment of appendicits in pregnancy
Surgery with IV antibiotics
Ranson criteria core stuff
Hemorrhagic complications
Renal insufficiency
etc. etc.
Treatment of basic symptomatic cholelithiasis in preggers
Low fat diet and observation until postpartum.
Threshold for bHCG and the detection of an intrauterine pregnancy
How many pregnancies in the US are extrauterine
Most common reason for maternal mortality in the first 20 weeks of pregnancy
Ectopic rupture --> hemorrhagic
Ectopic symptoms
Amenorrhea 4-6 weeks duration
Irregular vaginal spotting
Abdominal pain
Maybe shoulder pain

Adnexal mass is only palpable 50% of the time.
How to confirm hemoperitoneum in ectopic pregnancy rupture
Culdocentesis with aspiration of non clotted blood.
Risk factors for ectopic pregnancy
Tubal adhesive disease
Progesterone IUD
Tubal surgery
Prior ectopic
Ovulation induction
Congenital abnormalities of the tube.
How early can a pregnancy be detected via transvaginal ultrasoudn
5.5-6 weeks. Crown rump or yolk sac...
Problem with ectopics and the detection of IUP
Ectopic pregnancies can often be associated with fluid int he gestational sac, a so called pseudogestational sac.
DDx of ectopic
Acute salpingitis
Rupture corpeus luteum
Acute appendicitis
Dysfunctional uterine bleeding
Adnexal torsion
Degenerating leiomyomata
Repeat HCG, normal rise
48h --> a risein HCG of at least 66% above the initial level. Lack of appropriate rise --> indicative of abnormal pregnancy (ectopic or intrauterine). Levels that plateau after 48 hours --> something weird is going on.r
Other markers besides HCG for assessing pregnancy health
Progesterone >25 --> almost always correlates with a normal intrauterine pregnancy.
<5 --> almost always correlates with something not right.
Methotrexate dosing in ectopic
One time low dose IM
Ectopics <4 cm in diameter

highly effective!! 85-90% of cases. If bHCG levels do not fall, then second dose.
Size for MTX to be helpful in ectopic
<3.5 cm in size
Bleeding in the first trimester
Very early, it can be normal. This is during when the embryo implants into the wall of the uterus.
Anemia in pregnancy
8-10 mild
Severe <7
Sickle cell anemia cause
Point mutation in beta chain in which the amino acid glutaomic acid is replaced with valine. The result is improper folding of the hemoglobin molecule which results in either sickle cell disease or sickle cell trait.
What may especially trigger a G6PD deficiency
Antimalarial drugs
Pregnancy in sickle cell, one core recommendation
Stay hydrated. With proper prenatal care, these women can have perfectly normal pregnancies.
Two most comon causes of microcytic anemia
Iron deficiency
What is an electrophoresis result suggestive of beta-thalassemia disorder
Elevated A2 hemoglobin
Most common cause of megaloblastic anemia in pregnancy
Folate deficiency
Examination results that indicate preterm labor in a nulliparous woman
2 cm dilation
80% effacement
Objective tests for preterm delivery risk
- Transvaginal cervical length ultrasound measurements --> shortened cervix, funneling or beaking of the amniotic cavity into the cervix.

- Fetal fibronectin assay
IM antenatal steroids when
<34 weeks gestation...
Underlying causes for preterm labor
Cervical infection
Generalized infection
Trauma or abruption
Multiple gestations
Drugs used for tocolysis
Mg? Ineffective
Cervical length less than what correlates with what sort of increased risk of preterm delivery
Preterm labor incidence
11% of all pregnancies. Occuring between 20-37 weeks GA.
Risk factors for preterm labor
Multiple gestations
Previous preterm labor or birth
Uterine anomaly
Hx of cervical cone biopsy
Cocaine abuse
AA race
Abdominal trauma
Abd surgery in pregnancy
Speculated mech of mag for preterm labor
Competes with calcium for actin-myosin interation, thus decreasing myometrial activity. Has notbeen shown to be effective.
Nifedipine mechanism and sid effects
Inhibits voltage activated calcium channels thus decreasing voltage activated calcium channels.
Side effects: Pulmonary edema, respiratory depresion, neonatal depression.
Complication of indomethacin for preterm labro
Closure of ductus arteriosus --> severe neonatal pulmonary hypertension.
When are steroids given , what gestational age
24-34 weeks, when no risk for infection. In the early gestational ages, the effect is to lower the risk of intraventricular hemorrhage. In later ones (>28 weeks), th emain goal is to lower incidence of respiratory distress syndrome.
Prevention of preterm labor in women of high risk
Weekly injections of 17 alpha-hydroxyprogesterone from 20 weeks to 36 weeks.
What infection is strongly associated with preterm delivery
Gonococcal cervicitis. Chlamydia not as much.,

UTIs --> pylo as well.
BV maybe, but treatment of this does not seem to affect risk
Why are tocolytics CI in pregnancy
May preven the uterus from contracting in on itself post delivery
Tocolytic that may have profound effect on FHTracings
Indomethacin because it may caused decreased AFI --> oligohydramnios, which may increase risk for cord compression.
Tocolytic theray beta-agonist effects on mom
Tachycardia --> decreases diastoli filling time, leading to increased end diastolic pressure. Give oxygen, IV furosemide at decreasing IV fluid andthus decreasing hydrostatic pressure...

Beta agonist therapy is associated with an increased pulse pressure, hyperglycemia, hypokalemia, and tachycardia.
Dyspnea in a woman with preterm labor and tocolysis
Pulmonary edema
Negative cervical fibronectin assay, significance
Virtually guarantees no delivery for at least a week
Two most commn causes of vulvar ulcers in the United States
Chancroid is third but much less common.
Ulcer that is negative for HSV viral culture, syphilis (on darkfield as well)
Biopsy, presume chancroid
How is syphilitic latency divided
Early latent <1 year
Late latent >1 year
What is Benzathine Penicillin
Long acting penicillin, which acts well on the long replication time of T. pallidum.
Treatment of early vs late disease
Early - Benzathine PCN IM one injection 2.4 mil units
Latent - 2.4 mil units qW x 3

Neuro? IV PCN in the hospital.
Allergic to PCN, treatment for syphilis
Nonpregnant - Oral Erythromycin or doxy
Pregnant - PCN is the only known effective treatment to prevent congenital syphilis.
After syphilis therapy, monitoring
Nontreponemal test followed q3m x1 year. Appropriate response is a fourfold drop in titers in 3 months, and a negative titer in 1 year.
What happens if syphilis titer does not drop appropriately following treatment
?neurosyphilis??, may be diagnosed via LP
Ulcer of chancroid
Tender with ragged edges on a necrotic base. Tender LAD may also happen.
H. ducreyi is what
Small gram negative rod. Gram stain --> school of fish.

Dx via biopsy and/or culture.
Treatment of chancroid
Oral azithromycin or IM ceftriaxone.
RPR drops for a bit then rises substantially
SLE can also cause increase
Alternatives to PCN treatmetn for syphilis
Classic exam for neurosyphilis
Argyll Robertson pupils
Unsteady balance
Chorioamnionitis management
IV Amp and gent, induction of labor
Two most common acute complications of PPROM
Early sign of intraamniotic infection
Fetal tachycardia
LAtency period in labor
Duration of time from rupture of membranes to onset of labor
If speculum exam is negative but suspicion is high, what can be done
US looking for oligo
Risk factors for PPROM
Lower socioeconomic status
Cigarette smoking
Cervical conization
Emergency cerclage
Multiple gestations
Placental abruption
Prolonged rupture of membranes
Greater than 1 hour latency period
Steroids given when
24-32 or 34 weeks gestational age.
After what point is PPROM treated with delivery
>34-35 weeks gestational age.
Presenceof what in the vaginal pool amniotic fluid is indicative of fetal lung maturity
Chorioamnionitis without rupture of membranes?
Listeria --> transplacental spread.
Way to diagnose chorioamnionitis
Amniocentesis with gram stain
BV treatment
Metronidazole PO or vaginally
Clindamycin is an alternative

Targeting the anaerobes
Three most common causes of vaginitis or vaginosis
Why is BV worse after vaginal sex
?Alkaline semen?
Same for menses
What is the one cause of vaginosis that is not inflammatory
BV - just a predominance of anaerobes rather than a true infection.
Trich vaginalis
Frothy green discharge
Intensive inflammatory response
Strawberry cervix and all of that
Treatment for candida infection
Oral fluconazole
Imidazole cream
BV assoc with what
Genital tract infection such as endometritis, PID, pregnancy complications --> preterm delivery, preterm premature rupture of membranes
What may inhibit the movement of trichomonads on wet mount
IF the mount is cold
There are excess leukocytes present
Treatment of trich
One time dose 2g of metronidazole
Tinidazole also... for metro resistant cases.
pH of candida
Typically normal for the vagina, around <4.5.
KOH --> pseudohyphaes or hyphae. KOH lyses the leukocytes and erythrocytes making the ID of candida organisms easier.
Treatment for candida
Oral Diflucan
- Terconazole
- Miconazole (Monistat)
Most common cause of infectious vulvar ulcer disease in the US
Cystitis definition
>100,000 CFU of a single pathogenic organism on midstream voided specimen
Infection of bladder with bleeding
Gross hematuria may happen, but this should really raise suspicion of nephrolithiasis
What is considered bacteriuria
>10,000 CFU /ml on catheterized specimen
ASymptomatic bacteriuria, leads to infection in how many pregnant women
25% ---> pyelo

ASB complicates approx 8-10% of pregnancies
URethritis isolated organisms
Chlamydia, Gonococcus and Trichomonas

Suspect with symptoms of UTI but with sterile culture and no response to standard antibiotics.
Pregnant women w/ acute pyelo treated how
Amp and gent
Cephalosporin such as cefazolin, cefotetan, or ceftriaxone

Suppressive microbial therapy (such as nitrofurantoin macrocrystals 100mg once daily) for the remainder of pregnancy
GBS bacteriuria
IV PCN or ampiciliin in labor to reduce risk of neonatal sepsis
CI for an IUD
Recent STD
Behavior that inreaes risk for STDs
Abnormal size and shape of the uterus
Calendar method for contraception
PErfect use 9% failure, 25% typical use failure
Male condom method for contraception failure rates
Perfect use 2%, Typical use 15%
Combined hormonal contraception best for whom
Iron deficiency anemia
Ovarian cysts
Drawbacks to diaphragms
Higher rate of UTI
Increased risk of ulceration with prolonged usage
Progesterone only pill
Progestin does waht
Inhibits ovulation
Cervical mucus thickening
Estrogen does what
Maintain endometrium
Prevent unscheduled bleeding
Inhibit follicular development
Combined hormonal, besides thromboembolic risks
Benign hepatic tumors

MI in women smokers >35 yo.
BEnefits of combined OCPs
Decreases risk of ovarian and endometrial cancers
Shortens duration of menses
Decreases blood loss during menses
Improves pain from dysmenorrhea and endometriosis
Decreases dysfunctional uterine bleeding and menorrhagia
Improves acne
Besides thromboembolic events, CI to combined OCPs
Uncontrolled HTN
Migraines with aura
Diabetes with PVD
Smoking >35 yo
Known or suspected breast cancer
History of or known suspected estrogen dependent neoplasia
Undiagnosed weird genital bleeding
Benign or malignant liver tumors
ACute liver disease
Liver failure
Known or suspected pregnancy
Contraceptive patch
Ethinyl estradiol

qweekly, then by a week without a patch for withdrawal bleeding.
>90kg, efficacy is less.

Twice DVT risk than OCPs
Postpill amenorrhea
May last for up to 6 months
Mech of copper IUD
Inhibition of sperm migration and viability
Change in the transport speed of the ovum
Damage to or destruction of the ovum
Mirena mechanism
ATrophic endometrium
Cervical mucus

Can also be used to treat patients with menorrhagia, dysmenorrhea, and pain due to endometriosis and adenomyosis.
Current pregnancy
Current STD
Current or PID within past three months
Unexplained vaginal bleeding
Malignant gestational trophoblastic disease
Untreated cervical cancer
Untreated endometrial cancer
Uterine fibroids distoring cavity
Current breast cancer - levonorgestrel only
wilson disease - copper IUD only
Two most common regimens of emergency contraception
Yuzpe method - 0.1mg ethinyl estradiol, 0.5mg of levonorgestrel in two doses, 12h apart
Progestin only method - 0.75mg levonorgestrel in two doses taken 12 hours apart....

Mech: inhibition of ovulation, decreased tubal motility, and ?interruption of implantation.

ALSO!! IUD for emergency contraception up to 5 days afterward.
Which method is more effective for emergency contraception
Progesterin only - RR of 85%
Yuzpe - RRof 75% (about 8 to 2 in 100)
Side effect of emergency contraception
N/V esp with combined. Antiemetic is prescribed alon gtiwht this.
Birth control method assoc with OP or osteopenia
Depo shots.... possible
When is emergency contraception effective
When initiated up to 72 hours after intercourse
Why is migraine with aura a CI for combined birth control
Increased risk of strokes...
Why does the Yuzpe emergency contraception method have increased nausea/vomtiing
High dose of estrogen
Sickle cell anemia, what contraception is good
Depo shots
Epilepsy, what contraception method is good
Depo shots
Pyelo in pregnancy
IV amp and gentamicin
IV cefotetan or ceftriaxone
Complication of treating pyelo in preg with IV antibiotics
Endotoxin relased eut o lysed bacteria --> endotoxemia, possible ARDS with pulmonary injury due to the endotoxin release.

Can also damage myocardium, liver, kidneys, as well as the lungs.
Treatmetn for ARDS
supportive measures
Most common cause of sepsis in pregnant women
Treating pyelo in pregnancy, what happens if improvement is not seen after 48-72 hours
UTObstruction (ureterolithiasis)
Perinephric abscess
Pyelo in pregnancy, top complication
ARDS (2-5% of patients)

Also, endotoxemia may cause uterine contractions and possibly preterm labor.
When should asymptomatic bacteriuria be identified
First prenatal visit --> urine culture. Get a urine culture at every prenatal visit, regardless of fhx.