at what time point should a pt be evaluated for infertility?
after 1 year of regular unprotected intercourse
after 6 months if the woman is >35yo
What % of infertility is due to female-related factors?
what % of infertility is unexplained?
F = 65%f
U = 15%
what are common causes of female infertility?
-
Ovulatory Disorders
(PCOS, hypothyroidism, hyperprolactinemia)
-
Anatomic Abnormalities
(polyps, adhesions, leiomyomas)
Fallopian tube scarring (
STDs, PID
)
what tests should you perform on a female to assess for infertility?
-make sure the couple understands the physio on conception
-
assess for menstrual irregularities
-
Ovulation predictor kits
&
basal body temp
-
Pelvic US or Hysterosalpingogram
to assess for anatomical abnormalities
-
Hysteroscopy & Laparoscopy
: check fo
treatment options for female infertility:
-
Clomiphine
(MC)
-Give
exogenous FSH & LH (human menopausal gonadotropins)
to produce a "controlled ovarian hyperstimulation"
-Intrauterine Insemination
-In Vitro Fertilization (IVF)
what is the cause of Primary Dysmenorrhea?
overproduction of prostaglandins
what is the cause of Secondary Dysmenorrhea?
-
Caused by a dz
:
endometriosis (MC)
, infxn, fibroids, FBs, ovarian cysts, adhesions, PID, CA, ectopic pregnancy
What diagnostics would you want for Dysmenorrhea?
-
Hx
- Primary: how long, often, flow, FHx, sexually active, etc
- Secondary: Fever, bleeding, infxn, pregnant?
-
Pelvic exam/Pelvic US
�
Labs: CBC, UA
�
STI testing
g*: Chlamydia, GC, HIV and RPR (VDRL)
�
Pregnancy Testing
g* (1st test in suspected Secon
Tx for Dysmenorrhea:
�
Heat + NSAIDs = best option
� Diet, vitamin, herbs (Vit E, fish oil, fenyl, Mg etc)
� Behavior Modification
� TENS
� Exercise, yoga
� sexual activity
� acupuncture, relaxation, etc.
- OCP
what is the criteria for Primary Amenorrhea?
�
No menses by age 15
5* with normal growth and development
� No menses after 2 years after completing sexual maturation
what is the #1 cause of Secondary Amenorrhea?
Pregnancy
to be considered Secondary Amenorrhea, how long does the pt need to be without a period for dx?
3-6mo
Causes of Primary Amenorrhea:
�
Transverse vaginal septum or imperforate hymen
n* (outlfow obstruction)
� Hypothalamus-Pituitary failure (low LH/FSH)
�
Absence of uterus, cervix or vagina
�
Turner Syndrome (XO)
)*
� Chromosomal Abnormality
� Puberty Delay
Causes of Secondary Amenorrhea:
�
#1 = PREGNANCY
�
Female athlete triad
d*
�
Emotional stress, illness,; Idiopathic
� Prolactinoma*
�
PCOS
�
Asherman's syndrome
� Ovarian failure
Tests for Amenorrhea:
1. Beta HCG & pregnancy test
for secondary!
2. FSH & LH
3. TSH
4. Prolactin level
5.
Progesterone challenge test
US of uterus
Tx for Amenorrhea:
Clomiphene
= Hypothalamic Dysfunction
Tumor Removal
= Prolactinoma
OCPs & weight reduction
= PCOS
Histerectomy
= Asherman's
� *Physical, emotional or behavioral
sx occurring during the luteal phase (2nd half) of menstruation*
� Resolution of symptoms soon after flow begins
�
must be a sx-free interval during the follicular phase (1st half) to dx
PMS
PMS + one affective symptom (anger, irritability, internal tension)
PMDD
S/Sx of PMS:
� Abdominal bloating
� Fatigue
� Breast tenderness
� Headache
� Labile Mood
� Other
S/Sx of PMDD:
DSM-5 Criteria: 5 of the following with 1 from the 1st 4:
1. Feeling sad, hopeless
2. Feeling tense, anxious
3. Marked mood Lability, frequent tearfulness
4. Persistent anger, irritability; frequent interpersonal conflict
5. Decreased interest in usual ac
what are helpful tools in evaluating PMS?
�
Symptom calendar
r* -helpful in diagnosis and response to therapy
�
COPE calendar
r* -to verify luteal timing of symptoms
tx options for PMS:
� Education
�
Limit salt, refined sugar, caffeine, alcohol, fat, Increase complex carbohydrates and fiber
�
Vitamin B6
6*, Magnesium, Calcium, vitamin E
�
Evening Primrose Oil
�
Aerobic exercise
�
NSAIDS
Tx options for PMDD:
-
OCP w/ drosperinone
(
Yazmin
)
-
SSRIs
- for emotional sx
-Xanax (tranquilizer)
what is the MC cause of Secondary Dysmenorrhea?
What is the MC site for this to occur?
endometriosis
Ovaries
Causes of Dysfunctional Uterine Bleeding (DUB):
Usually a problem with the Hypothalamic-Pituitary-Ovarian axis from Non-Organic Causes:
-
P
olyp
-
A
denomyosis
-
L
eiomyoma
-
M
alignancy
-
C
oagulopathy
-
O
vulatory dysfxn (PCOS)
-
E
ndometrial
-Adrenal Hyperplasia
-Obseity
what is something to be very suspicious of that would cause
post-menopausal
bleeding?
Endometrial CA until proven otherwise
Diagnostics for Dysfunctional Uterine Bleeding (DUB):
DX OF EXCLUSION
-Pelvic exam
-Pap smear
-Endometrial bx if > 40YO to r/o cancer
-D&C
�
CBC w/platelets, PT, PTT , bleeding time
� hCG pregnancy test
� TSH
� NAAT & Culture for GC and Chlamydia
� FSH/LH
Diagnostics for post-menopausal bleeding:
� <5mm ? TVUS
� >5mm ? Endometrial Bx
� focal endometrial thickening ? hysteroscopy
Tx for Dysfunctional Uterine Bleeding:
1st line=
OCPs or IUD
(estrogen/progesterone based)
�
Hysterectomy
y* = definitive management
�
Endometrial ablation
Tx for post-menopausal bleeding:
Hysteroscopy with D&C
what are the 2 MC types of ovarian cysts?
1.
Follicular cyst
- follicle fails to rupture or follicle doesn't resolve after egg is released
2.
Corpus luteum cyst
- corpus luteum enlarges after ovulation instead of shrinks
Benign ovarian mass that contains tissue from all three germ layers and often have cartilage, bone, teeth and hair components.
teratoma
what is a risk associated with teratomas (dermoid cysts)?
they have a high rate of torsion
S/Sx of what?
-
Sudden onset of pelvic pain (90%)
-Adnexal mass
-N/V
-Fever
-Abnormal genital tract bleeding
Ovarian Torsion
what diagnostics would you do suspected functional ovarian cyst?
PELVIC US:
Follicular
= smooth, thin walled, unilocular
Corpus Luteum
= complex, thcker-walled with vascularity
hCG
to r/o pregnancy
Diagnostics for ovarian torsion:
Pelvic US w/
color-flow Doppler
Labs: hCG, Hct, WBC, electrolytes
what are common causes of adnexal masses?
-ovarian torsion
-ovarian CA
-follicular cysts
-ectopic pregnancy
what lab tests would you order for an adnexal mass?
Labs:
-
Pregnancy test
- CBC with diff
- CA 125
- UA
- possibly STI testing
-
pelvic US
what should you be very suspicious of if you're able to palpate an ovary in postmenopausal women or pre-menarche girls?
CANCER
Common S/Sx of adnexal masses:
-
Abrupt onset of pelvic pain or pressure/distension
- Fever
- Abnormal bleeding
- Ascites
- Hirsutism
what is the MC cause of infertility in women?
PCOS
what are women with PCOS at very high risk of developing?
-
metabolic syndrome
-diabetes
-endometrial CA
S/Sx of what?
1.
Amenorrhea
2.
Obesity
(40-85% of pts)
3.
Hirsutism
- insulin resistance
- Sleep apnea
-
Acanthosis Nigrans
- Depression, anxiety
- eating disorders
PCOS
what diagnostics would you do for PCOS?
1. Serum Testosterone
2. TVUS
Labs:
-
Serum hCG
, prolactin, TSH, FSH
- fasting lipids
-
oral glucose testing
or HgB A1C
ROTTERDAM CRITERIA (2/3):
1. Polycystic Ovaries on US
2. Oligomenorrhea or Amenorrhea
3. Signs of Hirsutism
Rotterdam Criteria for PCOS dx:
(Requires 2/3):
1.
Hyperandrogenism
(Clinically or blood tests)
2.
Ovulatory dysfxn
(Oligo or amenorrhea)
3.
Polycystic ovaries
"string of pearls
what are tx options for PCOS:
1st line =
diet & exercise for weight reduction
2nd line =
OCPs
- Spironolactone
- Metformin
- Clomid
Bladder
herniation through ANTERIOR
vaginal wall
Cystocele
Colon
herniation through
POSTERIOR
vaginal wall
Rectocele
Uterus or vagina sags or slips from its normal position:
Vaginal & Uterine Prolapse
uterine fibroids:
leiomyomata
�
Benign uterus smooth muscle tumor
r*�may be single or in clusters
�Grows within the wall of the uterus or into the interior cavity
�Growth is related to estrogen production
Leiomyomata
what is the MC pelvic tumor in women?
Leiomyomata
S/Sx of Leiomyomata:
-
Heavy or prolonged menstrual bleeding
-
Dysmenorrhea
-
Pelvic pressure and pain
- Reproductive dysfunction (infertility)
- bulk related sx
- blood clots
What can make Leiomyomatas better/worse?
-
worse in reproductive yrs
-
better/shrink after menopause
(due to decreased estrogen production)
FIBROIDS DEPEND ON ESTROGEN
who are Leiomyomatas MC in?
5x MC in AA
happens earlier and more aggressive
Asymmetric/irregular, hard, non-tender
, enlarged palpable abd/pelvic mass:
Leiomyomata
what diagnostic tests would you want for Leiomyomata?
TVUS
Labs: CBC, Hct, hCG, TSH
Saline-infusion sonography or hysteroscopy
Tx options for a Leiomyomata:
-
WATCHFUL WAITING
- OCPs
- Progestin Contraceptives
-
Leuprolide = most effective
-
HYSTERECTOMY = definitive tx
- Myomectomy
- Endometrial ablation
what are risk factors for Leiomyomatas?
-
AA
-
OBESITY
- Red meat and ham consumption
Scarring/adhesions inside the endometrial cavity, usually in response to uterine sx/procedure (abortion):
Asherman's syndrome
S/Sx of Asherman's syndrome:
-
Infertility
-
Recurrent pregnancy loss
- Menstrual abnormalities
- Pain
Tx for Asherman's syndrome:
Hysteroscopic resection of lesions
growth of endometrial tissue
outside
of the endometrial (uterine) cavity that responds to cyclical hormonal changes:
endometriosis
-
growth of glands
from the endometrium INTO the muscle wall of the uterus.
-Islands of endometrial tissue within the myometrium (uterine musculature)
adenomyosis
S/Sx of what?
1.
CYCLIC premenstrual pelvic pain
+/- LBP
2.
Dysmenorrhea
3.
Dyspareunia
- Dyschezia (painful defecation)
+/- spotting
- Infertility
- Worsens over time
- Worse with menses/ovulation
- Better w/ menopause
- Better/quiescent during pregnancy
endometriosis
what can make endometriosis better/worse?
- Worsens over time
- Worsens with menses/ovulation
- Better w/ menopause
- Better/quiescent during pregnancy
FIXED, tender
, adnexal masses/
nodules
on pelvic exam:
endometriosis
SYMMETRICAL, tender
, enlarged, &
"BOGGY uterus"
on pelvic exam:
adenomyosis
what diagnostics would you want to order with suspected endometriosis?
-TVUS
-EMB
-
laparoscopy w/endometrial bx
= definitive
- hCG, CBC, UA, STI testing
what are tx options for endometriosis?
-
NSAIDs + continuous OCPs
- surgery + assisted reproduction technology
- Refer to gynecology
Risk factors for endometriosis:
-
Caucasian and asian
-
Nulliparity
(never birthed a child)
-
THIN, LOW BMI
-
Prolonged estrogen
- Shorter menstrual cycle
- Heavy menstrual bleeding
- Obstruction of menstrual flow
- Exposure to DES in utero
- Height > 68 inches
- High consumption of tra
Tx options for adenomyosis?
Symptomatic
(still wants kids):
-NSAIDs + continuous OCPs
-GnRh agonist (leuprolide) OR Donazol - decreases estrogen
-skyla
Done having kids
:
-Total abdominal hysterectomy = definitive
-Uterine artery embolization (UAE)
what age are cervical polyps MC in?
What is the tx?
during the reproductive years, especially after age 40
Remove when symptomatic (bleeding, excessive discharge, large � 3 cm, or atypical appearing)
Occurs when eversion of the endocervix exposes columnar epithelium.
Common in adolescents
Cervical Ectropion
not typically tx
S/Sx of what?
-
pelvic or vaginal fullness, heaviness "falling out" sensation
- LBP
- vaginal bleeding, purulent DC
- urinary frequency, urgency, stress incontinence
cystocele, rectocele, uterine/vaginal prolapses:
Tx options for cystocele, rectocele, uterine/vaginal prolapses:
- Pelvic Floor/Kegel exercises
- weight loss
-
pessaries
- estrogen therapy
- hysterectomy
what is the MC gynecologic CA?
Endometrial/Uterine CA
Which gynecologic CA is "estrogen dependent"?
Endometrial/Uterine CA
what can endometrial hyperplasia lead to?
endometrial/uterine CA
what are common s/sx of endometrial/uterine CA?
-
inappropriate or excessive uterine bleeding
(postmenopausal bleeding)
- menorrhagia or metorrhagia
what diagnostic tests would you do for endometrial/uterine CA?
-
hysteroscopy with endometrial biopsy
= >4mm endometrial stripe
-
TVUS
what is the tx for endometrial/uterine CA?
- Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy
(TBA-BSO) + lymph node resection
- chemo or radiation
Risk factors for endometrial/uterine CA:
-
increased estrogen exposure
-
white women >50yo
-
chronic tamoxifen use
-
#1 = nulliparity
- chronic anovulation
- PCOS
- obesity
- late menopause
Risk Factors for Cervical CA:
-
HPV
- early onset sexual activity
- high number of partners
- smoking
- synthetic estrogen exposure (DES)
- STIs
- immunosuppresion
what is the MC cause of Cervical & Vulvar CA?
HPV 16 & 18
S/Sx of Cervical CA:
-
Post-coital bleeding/spotting
- metorrhagia
- pelvic pain
+/- watery vaginal discharge
what diagnostic tests would you do for Cervical CA?
1st = Pap smear w/cytology = screening
2nd =
Colposcopy w/bx
3rd =
cold knife conization w/bx
NAAT
what is the tx for Cervical CA?
-referral to gynecologic oncologist
-
cold-knife conization (fertility sparing)
-
total hysterectomy
-radiation or chemo
What are common causes of Vulvar CA?
-HPV
-DES exposure (synthetic estrogen)
S/Sx of Vulvar CA?
-
Pruritis, vaginal itching, irritation
- vulvar skin color changes
- vulvar contour changes
- Sores, lumps, or ulcers on the vulva that do not resolve
what is the MC type of Vaginal & Vulvar CA?
Squamous Cell CA
what is the tx for Vulvar CA?
-referral to gynecologic oncologist
-ablative (cryo/laser)
-Sx excision
-radiation or chemo
what is the tx for Vaginal CA?
- Refer to gyn onco
- Surgery
- Chemo/Radiation
what is the MC non-skin malignancy in women?
Breast CA
what is the 2nd MC cause of CA-related death?
Breast CA
what is the most significant risk factor for breast & ovarian CA?
-
BRCA1 & BRCA2
S/Sx of what?
-
SINGLE, painless, hard, IMMOBILE/FIXED breast lump
-
unilateral bloody nipple discharge
- red, swollen, warm, itchy breast
- asymmetric skin redness or discoloration
- changes in breast size, contour, nipple inversion
-
Paget's dz
: chroni
Breast CA
S/Sx of what?
-
solid, fixed, irregular palpable abdominal mass
- ascites
- Sister Mary Joseph's node:
- abdominal
bloating
/tenderness & early
satiety/fullness
- back or abdominal pain
-
urinary frequency and/or constipation
- irregular menses, menorrhag
Ovarian CA
what diagnostics would you want for suspected breast CA?
1. Clinical breast exam
2.
mammogram: microcalcifications
3.
US
(MRI if needed)
4. biopsy (FNA,
core
, open, punch)
what diagnostics would you want for suspected Ovarian CA?
-
TVUS
for screening then
Biopsy
-
CA-125 level
- Biopsy
Tx for breast CA:
- lumpectomy
- mastectomy
-
Sentinal & Axillary lymph node dissection
- chemo or radiation
- hormone therapy
-
Tamoxifen or Raloxifene
(SERM) can be used for prevention
Tx for Ovarian CA:
-
TAH/BSO
(Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy
- tumor debulking
- chemo
OCPs are protective
what is a protective factor against ovarian & endometrial CA?
OCPs
what can be used for prevention of breast CA?
Tamoxifen or Raloxifene (SERMs)
primary risk factors for endometrial hyperplasia:
- Excess estrogen
- Chronic anovulation (PCOS, perimenopause)
- MC post-menopausal
what is the best diagnostic tool for endometrial hyperplasia or CA?
Hysteroscopy w/bx
at what age should you begin screening for cervical CA?
when should you stop screening?
start 21 yo
stop: s/p total histerectomy or >65yo
If no history of abnormal Pap�every 3 years:
o21-24: Pap only
o25-29: Pap with reflex to HPV for ASC-US results
o� 30: Pap + HPV test from same sample (tests for high-risk HPV only)
what reporting system is used for PAP results?
Bethesda System
What test would you do next if you get an abnormal PAP?
Colposcopy
what is the tx for Cervical Intraepithelial Neoplasia (CIN)?
CIN 1 & 2 = close monitoring, no tx
CIN 3 =
excision (LEEP)
or
ablative (cryo/laser)
-Loop Electrosurgical Excision Procedure (LEEP)
-Conization
-Cryo therapy'
-Laser ablation
what are the s/sx of Vaginal CA?
- Asx
-abnormal vaginal discharge or bleeding
-Vaginal pain w/intercourse
-Pelvic or perineal pain-
tx options for Vaginal Intraepithelial Neoplasia (VaIN):
-Observation
-Fluorouracil (5-FU)
-Imiquimod
-Laser ablation
-Brachytherapy
S/Sx of Vaginal Intraepithelial Neoplasia (VaIN):
- ASX
- Abnormal vaginal discharge or bleeding
- Vaginal pain, particularly with intercourse
- Pelvic or perineal pain
Common causes of Vulvovaginal Candidiasis:
-
Recent antibiotics or steroids
-
Diabetes
- Increased estrogen levels
-
Pregnancy
,
- OCPs
- Estrogen therapy
- Immunocompromised
- Obesity
- Vaginal or vulvar irritants
S/Sx of what?
-
Vulvovaginal Pruritus (often intense)
- Erythema and swelling of the vulva
- Dysuria
- Vulvar and vaginal erythema and edema
-
Thick white odorless vaginal discharge
Vulvovaginal Candidiasis
Which diagnostics would you want for Vulvovaginal Candidiasis?
Wet mount slide or NuSwab: budding yeast
What is the tx for Vulvovaginal Candidiasis?
-
Fluconazole
single dose
-
Nystatin
- Intravaginal antifungal cream
- "pelvic rest"
-
control blood sugar
Recurrent:
- Fluconazole x 6mo
-
Boric Acid or Gentian Violet topically
what should pts avoid with vulvovaginal candidiasis?
douching, panty liners, pantyhose, cranberry juice and topical lubricants
What is the MC cause of vaginal discharge in women of childbearing age?
bacterial vaginosis
what is the cause of Bacterial Vaginosis?
overgrowth of
Gardnerella Vaginalis, anaerobes
due to a shift in the normal vaginal flora
S/Sx of what?
- May be Asx
-
"fish-rotten" vaginal odor, worse after sex
-
copious, thin, homogenous watery, OFF-WHITE vaginal discharge
+/- pruritis, dysuria, dyspareunia, erethema, edema (usually suggests mixed vaginitis)
Bacterial Vaginosis
When is the Amsel Criteria used for diagnosis?
What are the criteria?
Bacterial Vaginosis
-
(+) Whiff test:
fishy odor
- Culture:
Clue cells
- abnormal vaginal discharge
- ? pH >4.5
What diagnostics would you want for bacterial vaginosis?
Amsel Criteria: (3/4)
-
(+) Whiff test:
fishy odor
- Culture:
Clue cells
- abnormal fvaginal discharge
- ? pH >4.5
what is the tx for bacterial vaginosis?
-
Metronidazole (Flagyl)
-NO ETOH!
- Clindamycin -NO LATEX CONDOMS!
- "Pelvic rest"
- latex condoms may help
- Estrogen-containing OCPs
>3 episodes in 1 yr:
Metranidazole PO? boric acid ? metranidazole gel
what are pregnant women with bacterial vaginosis at risk of?
preterm delivery & postpartum infxn
what is the normal vaginal pH?
4-4.5
who is atrophic vaginitis MC in?
menopausal women
S/Sx of what?
-
vaginal dryness
, burning, pruritus
-
dyspareunia
-vaginal discharge, bleeding or spotting
-dysuria, urinary frequency, urethral discomfort, hematuria, recurrent UTIs
- scarce pubic hair, diminished elasticity of vulvar skin
-
introital na
Atrophic Vaginitis
What is the tx for atrophic vaginitis?
intravaginal estrogen preparations/creams
S/Sx of what?
2 peaks: prebuteral & peri/post menopausal
-
vulvar pruritis so intense it interferes with sleep
- vulvar pain
- pruritis ani, painful defecation & anal fissures
- dyspareunia
-
white atrophic papules/plaques
Vulvar Lichen Sclerosis
how is Vulvar Lichen Sclerosis diagnosed?
Clinical but confirmed by biopsy
What is the tx for Vulvar Lichen Sclerosis?
topical steroids
what is the tx for Lichen Simplex Chronicus, Lichen Planus, & Vulvar Dermatitis?
- Remove offending agent
- sitz baths & cool compresses
- anti-pruritic agents (benadryl)
-
topical steroids
- *calcineurin inhibitors (tracrolimus)
what are pts with Vulvar Lichen Sclerosis at risk of developing?
SCC of the vulva
What is the tx for a bartholin cyst?
What is the tx for a bartholyn abscess?
Cyst: PAINLESS
-
no tx needed
in most cases
Abscess: PAINFUL
-
I&D w/packing & abx
-
Word catheter insertion w/abx
if the pt has cellulitis
- surgical excision
- tx for STI if suspected
Who are Labial Adhesion/Agglutination MC in?
infants & young children
what causes Labial Adhesion/Agglutination?
-
Inflammation of the labia minora + low estrogen
, poor perineal hygiene, trauma, vaginal infection or lichen sclerosis
Labia fused together:
Labial Adhesion/Agglutination
what is the tx for Labial Adhesion/Agglutination?
-
topical estrogen therapy
- topical betamethasone
- refer for sx (if refractive)
Vulvar pain of at least 3 months duration w/out a clear cause:
Vulvodynia
Ability to recreate pain with a cotton swab is indicative of which condition?
Vulvodynia
S/Sx of what?
�Early�tenderness, palpable nodule
�Mid-late�flu-like symptoms
�Late�red, hot, and shiny breast/areola
mastitis
diagnostics for mastitis:
- culture
-needle aspiration
-if not improving do an US and diagnostic mammogram
-
UNILATERAL breast pain (especially in 1 quadrant)
-tenderness, warmth, swelling & nipple discharge
-
F/C, flu-like sx
mastitis
what is the tx for mastitis?
-
Amoxicillin (Augmentin) and NSAIDS
-Cephalexin or Bactrim
-Heat & warm compresses
-
I & D
- Chronic = surgical excision of the affected duct or lobule
what is the primary risk factor associated with mastitis?
smoking!
what is the tx for a breast abscess?
-
I&D + antibiotic therapy
- D/C breastfeeding (if nursing)
what is the tx for candidiasis of the breast/Intertrigo?
Treat mother AND baby
-Topical
nystatin
cream (mom) and liquid (baby)
-Topical
clomitrazole
-Oral
fluconazole
-
Gentian violet
?%
-Barrier cream (for friction)
-short term steroids for inflammation
what is the cause of galactorrhea?
hyperprolactinemia from
medications
pituitary adenoma
or other conditions
what should you look for on PE of galactorrhea?
- Breast exam�elicit discharge (multiple ducts)
- Check for chiasmal syndrome (eg bitemporal field loss)
- Check for signs of hypothyroidism and
Hypogonadism
what diagnostics would you do for galactorrhea?
PE:
- Breast exam�elicit discharge (multiple ducts)
- Check for
chiasmal syndrome (eg bitemporal field loss)
- Check for signs of hypothyroidism and
Hypogonadism
Labs:
- Pregnancy test
-
Prolactin level
- CMP
- Thyroid Panel
CT/MRI of the brain
what is the tx for galactorrhea?
refer to endocrinology
what is the MC disorder of the breast?
Fibrocystic Breast
Fluid-filled breast cyst
due to exaggerated response to hormones
Fibrocystic Breast
S/Sx of what?
-
BILATERAL tender/painful, mobile, well-demarcated lumps in breast
-
usually multiple
- may grow/shrink with menstrual hormone changes
Fibrocystic Breast
S/Sx of what?
- smooth, well-defined, non-tender/painless, rubbery, MOBILE mass
- gradually grows over time (does NOT grow/shrink w/menstruation)
- may grow with pregnancy or estrogen therapy
Fibroadenoma
Benign solid tumor of the breast
that contains glandular and fibrous tissue
Fibroadenoma
what is the tx for fibroadenoma?
Observation, with US monitoring (q3-6mo for 2yr)
+/- excision
what is the tx for Fibrocystic Breast?
Most resolve spontaneously
Breast US & FNA removal of fluid if symptomatic (
"straw colored fluid"
)
Ascending infection from the cervix to the upper genital tract:
Pelvic Inflammatory Dz (PID)
what is the cause of PID?
-
Mixed N. Gonorrhea & Chlamydia
- G. Vaginalis, anaerobes, H. flu, etc.
S/Sx of what?
-
BILATERAL lower abd pain
-
purulent cervical & vaginal DC
+/- bleeding and odor
-
fever > 101 w/ chills
- dysuria
- dyspareunia
-
Chandelier sign
: cervical motion tenderness on exam and severe pain- pt will jump off table*
PID
what diagnostics would you do for PID?
-
NAAT
(Chlamydia & Gonorrhea)
-pregnancy test
-CBC, UA
-
laparoscopy
what is the tx for PID?
Outpatient:
Doxycycline + Ceftriaxone
Inpatient:
- IV doxycycline + 2nd gen ceph (Cefoxitin or Cefotetan)
- OR Clindamycin + Gentamicin
what is the MC STD in the US?
2nd MC?
1st = Chlamydia
2nd = Gonorrhea
what is the MC cause of cervicitis?
Chlamydia
Gram negative diplococci causing STI:
Neisseria gonorrhoeae
diagnostics for chlamydia:
-Cervical swab or urine culture
- NAAT (Nucleic Acid Amplification Test) most sensitive
diagnostics for gonorrhea:
� NAAT (Nucleic Acid Amplification Test)
� cultures and genetic DNA probe
- urine
- rectal swab
S/Sx of what?
May be ASX in males and females
- Dysuria, vaginal discharge, dyspareunia'
- bleeding bw periods & after sex
-
mucopurulent drainage from os
- Lower abd pain/pelvic pain (PID)
-
rectal sx
-
conjunctivitis
-
pharyngeal sx
chlamydia
May be Asx
-
copious amount
of
mucopurulent drainage from cervical os
-bleeding bw periods and after sex
- dysuria/uretheral discharge
-dyspareunia
-bartholin gland can become infected and abscess
-lower abd pain (PID)
gonorrhea
S/Sx of what?
-often ASX
-
vulvar pruritus & burning
-
purulent, malodorous, frothy yellow-green discharge
-
"strawberry cervix"
- dysuria, frequency
- dyspareunia
- vulvar/vaginal erythema
Trichomoniasis
Diagnostics for trichomoniasis:
-
Wet Mount: motile trichomonads
and WBC
-rapid trichomonas test in office
Tx for gonorrha:
�
Ceftriaxone 250mg (IM)
)*
� Doxycycline or Azithromycin (to cover chlamydia)
Tx for chlamydia:
�
Azithromycin
n* single dose
�
Doxycycline
e* bid x 10d
� Ceftriaxone (for gonorrhea)
Alternative treatments:
Ofloxacin or Levofloxacin
Tx for trichomoniasis:
Metronidazole(flagyl)
most prevalent STI in the US?
HPV
S/Sx of what?
- ASX in most women
-
Prodromal sx 24hr prior: burning, paresthesias, tingling
�
Painful genital ulcerations
s*
� Dysuria
� Fever
� Pruritus
� Tender inguinal lymphadenopathy
� Headache
- 1st episode is the most severe
Herpes Simplex Virus
Diagnostis for Herpes:
Clinical Dx
-
PCR
-
Viral Culture
- NAAT
- Direct Fluorescent Antibody
-
Tzanck smear: multinucleated giant cells
Tx for HSV:
�
Acyclovir, Famciclovir, Valacyclovir
r*
� Analgesics for pain
- monitor: untx will heal in 2-3wk
- Consider daily prophylaxis for individuals who get frequent outbreaks
What causes Molluscom Contagiousum
DNA Poxvirus
Spread by skin to skin contact, scratching or rubbing lesions (sharing towels, bedding, toys)
HIGHLY CONTAGIOUS
what is the cause of Chancroids?
Haemophilus Ducreyi
- gram neg bacillus
what is the cause of pubic lice?
Phthirus pubus
what is the cause of scabies?
Sarcoptes Scabiei
what is the cause of Lymphogranuloma Venereum (LGV)?
Chlamydia trachomatis
HIV+ is risk factor
Chronic (long-term) infection of the lymphatic system caused by Chlamydia:
Lymphogranuloma Venereum (LGV)
Description of what?
Small, painless, dome-shaped papule w/
central umbilication
on genitals, inner thighs & buttocks
Malluscum Contagiousum
S/Sx of what?
-
Soft, shallow, PAINFUL "punched-out" genital ulcer
- Painful adenopathy
+/- foul-selling DC from ulcer
chancroid
S/Sx of what?
3-12d:
painless, genital ulcer
10d-6mo:
-
unilateral inguinal lymphadenopathy
- draining lymph nodes
- rectal fistula
- vulvar/labial swelling
Lymphogranuloma Venereum (LGV)
How do you diagnose sabies?
Mineral Oil Skin Scrapings or Burrow Tracts found
Tx for molluscum contagiousum:
-
normally heals on its own 6-12mo
- salicylic acid or potassium hydroxide
- topical retinoids
-cryotherapy or laser therapy
- scraping
Tx of Chancroid:
Ceftriaxone or Azithromycin
Tx for Pubic Lice & Scabies:
Permethrin rinse
Tx for Lymphogranuloma Venereum (LGV):
Doxycycline
which STI is known as the "great imitator" bc the rash and dz can present in many different ways similar to other dzs?
syphilis
What is the cause of syphilis?
Treponema pallidum
which phase of syphilis?
Small firm
PAINLESS "punched out"
appearing sore (chancre) with rolled edges
primary
Which phase of syphilis?
Diffuse, symmetric, macular/papular red-rown rash
on extremities and trunk especially palms and soles!
- wart-like sores (flat topped papules)
-
myalgias, fever, sore throat, lymphadenopathy
secondary
Gummatous syphilis is seen in which phase?
tertiary
what is the tx for syphilis?
penicillin G
what diagnostic tests are used for syphillis?
- Treponemal test (
FTA-ABS or TP-PA
) #1
- Non-treponemal test (VDRL, RPR) -
NOT used for dx alone
what is the difference between syphillis & chancroid?
-syphilis is PAINLESS caused by treponema pallidum; tx w/pen G
-chancroid is PAINFUL caused be hemophylus ducrae; tx w/flagyl
what age group/when does primary vs secondary dysmenorrhea occur?
primary =
ONLY during menses
, usually within 2 years of menarche (peaks late teans-early 20s)
secondary =
>20yo & progresses with age
. Not associated with menstruation
what is needed for diagnosis of PMS?
there must be a sx-free interval during the
follicular phase (1st half)
to dx
what is the criteria for
premature
menopause?
what is a major risk factor?
<40yo
SMOKING
S/Sx of what?
- menstrual cycle changes
-
hot flashes
(vasomotor symptoms)
- mood changes
-
skin thinning, facial hair increases, brittle nails
-
osteoporosis
- dyspareunia due to
vaginal atrophy
- urinary incontinence
- atrophic vaginitis
Menopause
what diagnostics COULD you do to for menopause?
DX MADE CLINICALLY: no menstruation x 12 mo
FSH may be unreliable
-
FSH assay: 21 - 100 mU/mL
(serum ? FSH, ? LH, ? estrogen)
- TSH (r/o hyperthyroidism as cause of hot flashes)
- hCG (r/o pregnancy as cause of amenorrhea)
- DXA scan
- vaginal exam (for a
what is the tx for menopause?
-
HRT
of estrogen, progesterone
-
calcium + vitamin D
&
bisphosphonates
for osteoporosis
-
topical estrogens
&
lubricants
for urogenital atrophy & discomfort
-
topical lubricants (Astroglide)
- clonidine, SSRI/SNRI, Gabapentin
-
Black Cohish
what is a major risk factor for premature menopause?
smoking
when does DUB usually occur?
MC occurs shortly after menarchy & during perimenopause because of increased anovulatory cycles
what are women with leiomyomata's at increased risk of developing?
-4x more likely to get endometrial CA
-spontaneous abortion
what is the tx for ovarian cysts?
-
Most resolve spontaneously in a couple weeks
but can persist for several months
- OCPs
- Surgery if cyst doesn't resolve
string of pearls" on US indicates which condition?
PCOS
which CA has the highest mortality rate?
Ovarian CA
breast tenderness:
Mastodynia
Peau d-orange is seen with which condition?
breast CA
in which condition would you see Chandelier sign (cervical motion tenderness)?
PID
What should be done at the first gynecological visit for pregnancy?
when should this take place?
1. Maternal Blood Screening tests ~11-13 weeks
-Inherited disorders (eg, cystic fibrosis, fragile X, spinal muscular atrophy, hemoglobinopathy)
-Fetal aneuploidy (eg, trisomy 21)
-Thyroid disease
-Lead
-
nuchal translucency US
-
Hgb/Hct, UA/UC, CBC, STD t
What should be done at the first trimester visit?
-PAPP-A (can detect down syndrome)
-hCG
-Nuchal translucency
-
US: fetal heart activity
-CVS (if indicated)
-Crown-Rump Length (CRL) or Naegel's Rule
at what point could you hear fetal heart tones on US?
HR?
9-12weeks
~6weeks
what should be done at the 2nd trimester visit?
QUAD SCREENING:
- MSAFP (Maternal Serum Alpha fetoprotein)
- B-hCG
- Estradiol
- Inhibin
-US
-amniocentesis (if indicated)
what should be done at the 3rd trimester visit?
1.
Gestational Diabetes screening
~24-28wks
2.
RhoGAM
if indicated
3.
Group B Strep screening:
32-37wks
(+) needs intrapartum abx
4.
Hgb/Hct, UA/UC, CBC, STD testing
5.
Fetal breathing, heart tones & movement
where do 95+% of ectopic pregnancies occur?
why?
Fallopian tubes
The lack of a submucosal layer
allows for easy wall access and implantation of the fertilized ovum.
what is the MC cause of ectopic pregnancies?
adhesions
s/sx of what?
Triad:
1. UNILATERAL pelvic/abd pain
2. Vaginal bleeding
3. Amenorrhea or spotting
ectopic pregnancy
what are the s/sx of a ruptured ectopic pregnancy?
-
Sudden, severe abd pain
- dizziness
- N/V
-
signs of shock(syncope, hypotension, tachy)
- severe blood loss
what diagnostics would be done for an ectopic pregnancy?
-
hCG <2,000
-
US:
absence of gestational sac
what is the tx for an ectopic pregnancy?
ruptured ectopic pregnancy?
1. Stable =
Methotrexate
2. ruptured/unstable =
laparoscopic salpingostomy
Involuntary termination of pregnancy BEFORE 20 weeks:
spontaneous abortion
when are spontaneous abortions MC?
1st trimester
what is the MC cause of spontaneous abortions in the 1st trimester?
chromosomal abnormalities
what are the tx options for spontaneous abortions?
need to completely empty uterus
-
misoprostol
-
D&C
-Rh = immunoglobulin
-Septic = abx
diagnostics for molar pregnancy:
hCG: >100,000
(markedly elevated)
US:
-
complete =
"snowstorm" or "cluster of grapes" appearance
-
partial =
absence of fetal parts & heart sounds
when would you see a "snowstorm" or "cluster of grapes" appearance on an US?
complete molar pregnancy
what is the tx for molar pregnancies?
suction curettage & hysterectomy
metastatic = methotrexate & chemo
at what point is it considered preterm labor?
<37weeks
� Uterine contractions >6/hour for over 2 hours
� Cervical dilation >2 cm or cervical shortening
� Documented cervical change by same examiner
what is the MC cause of perinatal mortality (neonatal deaths)?
preterm labor
what are tx options for preterm labor?
Outpatient: FU in 2 wks for US
- Off work, bedrest, hydration
"Its Not My Time"
I
ndomethacin
N
ifedipine
M
ag Sulfate
T
erbutaline
-
Makena
(17 OH progesterone)-Give 1 shot per week after 16wks gestation.
-Vaginal Progesterone Suppositories
In Patient:
-
what is a major risk factor for PROM?
infection
diagnostics for PROM:
-
Pooling of fluid on speculum
-
Nitrazine paper test
: turns blue of pH >6.5
-
Fern test
- US: decreased AFI
- Valsalva maneuver can show fluid leakage
a gush of fluid OR persistent leakage of fluid from the vagina indicates what?
Premature Rupture of Membranes (PROM)
HTN + Proteinuria +/- edema AFTER 20 weeks gestation:
preeclampsia
Seizures or coma in pts who meet preeclapsia criteria
LIFE-THREATENING FOR MOTHER & FETUS
eclampsia
S/Sx of what?
1. HTN 2. EDEMA, 3. PROTEINURIA
-
severe HA refractory to Tylenol
- persistent visual changes
- epigastric or
RUQ pain
- sudden severe
swelling in face & hands
"I just don't feel right
Preeclampsia
what is the difference in sx between preeclampsia & eclampsia?
Eclampsia will have HTN, edema, & proteinuria
+ seizures
Highest risk of seizure is during labor and through the 1st 24h post-partum
Diagnostics of what?
Mild: BP >140/90
- 2x at least 6 hrs apart
-
proteinuria >300mg (0.3g)/24hr
Severe:
BP >160/110
-
Proteinuria >5g/24hr
- oliguria
- thrombocytopenia
-
HELLP syndrome
Hemolytic anemia
Elevated Liver Enzymes
Low Platelets
preeclampsia & eclampsia
what is the MC risk factor for preeclampsia?
nulliparity
what are tx options for preeclampsia?
Mild:
- >37weeks = delivery
- <34weeks = steroids to mature lungs
Severe:
-
prompt delivery is only cure!
- hospitalize & give
Mag Sulfate
- BP meds for acute severe HTN
what are tx options for eclampsia?
- ABCDs
-
Mag Sulfate = 1st line for seizures
- Lorazepam = 2nd line
-
DELIVERY
once pt is stabalized
- BP meds:
hydralazine, labetolol
what are the common causes of
3rd trimester
bleeding?
1. Placenta Abruptio (MC)
2. Placenta Previa
3. Vasa Previa
4. Placenta Accreta
Premature separation of normally implanted placenta AFTER the 20th week but before birth
Abruptio Placentae
Placenta partially or completely covers the
cervical os:
Placenta Previa
S/Sx of what?
PAINLESS bright red vaginal bleeding in the 3rd trimester
Placenta Previa
what is diagnostic test you would want for placenta previa?
- TVUS
- Rh Type & Screen
-DO NOT DO A PELVIC EXAM!
what is the tx for placentia previa & abruptio placenta?
C-section
what are the MC causes of postpartum hemorrhages?
what are the 2 stages?
-
Uterine atony (MC)
- Uterine rupture
- Bleeding disorder
- DIC
primary (early) = 1st 24hrs
secondary (late) = 24hrs to 12wks
criteria of blood loss in postpartum hemorrhage?
Bleeding >500ml if vaginal delivery
Bleeding >1000ml if C-section
what tests would you do for postpartum hemorrhage?
CBC,
Hgb/Hct, PT/PTT/INR, platelets
US
tx options for postpartum hemorrhages?
1st =
bimanual uterine massage & compression
2nd =
oxytocin IV, misoprostol, methylergonovine
3rd = direct internal compression with uterine packing or balloon compression devices
4th = Surgical:
-uterine compression sutures
-Arterial ligation - assoc wit
the 6 week period following delivery
the period of time from delivery of the placenta & membranes to return of the reproductive organs (and rest of body) to non-pregnant state.
Puerperium
Tx options for PROM:
-CEFM and Toco
-Tx GBS if needed
-Rhogam
what should you do when labor begins?
� Admit to L&D
�
Vitals q1-2hrs
s*
� OK to ambulate unless fetal status an issue
� Hep/Saline Lock =
IV fluids
� CEFM or intermittent protocol
� If GBS pos - start ampicillin q4h
�
Pain management
t* if desired
what are pain management options for labor?
- Epidural
- Spinal Anesthetic
- Pudendal Block
- Local Anesthetic
- Benadryl, morphine, dilaudid, vistoril, stadol, nubain - can cause respiratory depression
what are methods to induce pregnancy?
�
Amniotomy (Artifical ROM)
� Cervical ripening with Misoprostol (Cytotec)
� Foley bulb when 1-2cm dilated
� Oxytocin/Pitocin to get regular UCs
at what point is labor considered post-term?
>42weeks gestation
what is the MC cause of post-term pregnancy?
inaccurate dating
what will help determine which method of induction is needed for labor?
Bishop Score
(>6 is favorable)
what can a PA do to induce labor?
Bishop Score determines mode of induction
�
Oxytocin (Pitocin)
)* to get regular UCs
�
AROM
M* when regular UCs
�
Membrane stripping
� Strip membranes with aggressive sweeping motion on SVE
� Cervical ripening with Prostaglandins (Cytotec, Cervidil, Prost
what 3 methods can be used to monitor labor?
� Continuous external fetal monitoring (CEFM)
� fetal scalp electrode (FSE)
� Continuous tocometer
What do you need to assess to determine degree of labor?
�
Cervical Dilation:
:* Opening of cervix
�
Cervical Effacement:
:* Thinning of cervix measured by %
�
Position:
:* Posterior, mid-position or Anterior
�
Consistency:
:* firm, medium or soft
�
Station:
:* Descent of baby's head in relationship to maternal
what are pain management methods for prodromal labor sx?
- warm bath w/epsom salts
- benadryl or Tylenol PM
- glass of wine
- hydration
- sleep
what are the 5 components of a cervical exam for labor?
1. dilation
2. effacement
3. station
4. position
5. consistency
When the baby's shoulders get stuck during labor this is called...:
shoulder dystocia
OBSTETRIC EMERGENCY!
what are the 2 signs of shoulder dystocia?
(1) The baby's body does not emerge with standard traction and maternal pushing after delivery of the fetal head.
(2)
"turtle sign"
- fetal head suddenly retracts back against the mother's perineum after it has emerged from the vagina. The baby's cheeks b
what are delivery options for shoulder dystocia?
�
McRoberts
s*: hyperflexion of knees to shoulders with suprapubic pressure
�
Episiotomy
y* if needed
�
Rotate shoulders
�
Deliver posterior arm
�
Break Clavicle and/or humerus
�
Zavanelli Maneuver
r*: Push fetal head back in and perform emergent C/S
Abnormal placental development of trophoblastic tissue
proliferation arising from gestational tissue:
Molar Pregnancy (Gestational Trophoblastic Dz)
S/Sx of what?
-
PAINLESS vaginal bleeding +/- browinish discharge
-
uterine size/date discrepancies
- preeclampsia <20wk
-
hyperemesis gravidarum
- choriocarcinoma
Molar Pregnancy (Gestational Trophoblastic Dz)
Severe form of N/V during pregnancy? Ketonuria, Dehydration & Significant weight loss >5%
Hyperemesis Gravidarium
what is the Amniotic Fluid Index (AFI) in Oligohydramnios?
what is it in Polyhydramnios?
oligo = <5cm
poly = >20cm
pinking/brown vaginal bleeding especially days 4-10 after delivery. Usually resolves by 3-4 weeks
Lochia Serosa
what are options for performing an elective abortion?
<10wks ? misoprostol (cytotec) or methergine
10-12wks ? D&C
12+ wks ? D&E
WHAT tests should you do for Gestational DM?
WHEN should you do these test?
- oral glucose challenge test
- GTT to confirm
do at 1st trimester screening then again in 3rd trimester ~24-28wks
what are some indications for C-Sections?
-maternal exhaustion
-fetal intolerance
-minimal descent with pushing
-malrotation of fetal vertex
>2hrs of ACTIVE labor with no cervical change:
Failure To Progress
Fetal stool in utero:
Thick, tarry, black & comprised of lanugo, fetal intestinal cells, amniotic fluid, bile
Meconium Passage in Utero
what is the MC cause for hospital admission in first trimester?
Hyperemesis Gravidarium
tx options for Hyperemesis Gravidium:
85% resolve by 16wks
� Alternating antiemetics: Zofran/Phenergan, Reglan/Diclegis
� IV hydration
� Vit B6, Multivitamin, 1L D5LR or D5NS
what are the MC organisms to cause Cystitis (UTI) & Pyelonephritis (kidney infxn)?
E. coli (MC)
Klebsiella, Group B Strep
what is a Major cause of maternal morbidity & mortality?
Pyelonephritis
Generalized unrelenting pruritus affecting entire body with no associated rash, usually affecting the palms & soles:
Cholecystitis in Pregnancy
S/Sx of what?
-
F/C
, tachycardia, tachypnea
- N/V
- unilateral
CVA tenderness
- Uterine irritability or UC
- Dysuria,
hematuria
- Fetal tachycardia
pyelonephritis
what tests should you do for cystitis?
UA:
(+) leuk (WBC >10)
(+) nitrites
C/S:
>10^5 CFU
what tests should you do for pyelonephritis?
-CBC
-UA: WBC Casts
-C/S
-Renal US: hydronephrosis
-CXR
what tests would you do for cholecystasis in pregnancy?
Quad Screen: elevated serum analytes >2.5
? Serum Bile Acids (not bilirubin)
PET
what is the tx for cystitis?
Macrobid
What is the tx for Pyelonephritis
� IV Hydration
�
IV Cefazolin or Amp/Gent
&
continuous Macrobid
� Tylenol
� Expect a spiked fever curve; keep inhouse until 48* afebrile
� Tocolytics if indicated
� Cooling measures
what is the tx for cholecystitis in pregnancy?
-
Ursadiol
- benadryl
- deliver at 37 weeks
what should you do to test for Rh compatibility in pregnancy?
Screen each woman at first prenatal visit with
Rh Type and Antibody Screen
Kleinhauer-Betke test
- If there is concern for poss maternal-fetal hemorrhage
what tests should you do for Intrauterine Growth Restriction (IUGR)?
�
Umbilical Artery Dopplers
� US
�
Fundal Height & weight
t* - <10% p
� US
� AFI
what will Intrauterine Growth Restriction (IUGR) do to the fetus?
cause lack of reserve for labor & continued intrauterine life (wants to get out); fetus is abnormally small due to restrictions
-
stillbirth
-
Low birth weight
-Difficulty handling the stresses of vaginal delivery
-Decreased oxygen levels
-Hypoglycemia (l
what is given for Group B Strep (GBS) in pregnancy?
� Ampicillin
� Clindamycin if PCN allergic
� Vancomycin
what is a risk factor for monozygotic (identical) twins?
what is a risk factor for dizygotic (fraternal) twins?
- ART? monozygotic twins
- increased maternal age ? dizygotic twins
what are delivery options for breech presentation?
�
Pinard: Flexion
n* at knee to deliver legs/hips
�
Mariceau Smellie Veit
t*: Flexion of fetal head via fingers on maxilla, and one in open mouth to flex chin downward
�
External Cephalic Version (ECV)
)*: a process by which a breech baby can sometimes be
what are the 3 types of breech presentation?
which type is the most dangerous?
1. complete
2.
footling
(most dangerous)
3. frank
what tests should you do after traumas in pregnancy?
-
maternal stabilization most important
- vitals
-
CBC, PT/PTT/INR, D-dimer, fibrinogen
-
Kleihauer-Betke test
: Determines Maternal Fetal Hemorrhage
- Type and Screen: Rhogam if Rh neg!
-
Fetal heart tones
- NST
- US
what are treatment options when a trauma in pregnancy occurs?
Be prepared for massive hemorrhage!
-
immediate delivery
- volume resuscitation
- keep track of blood loss
what are the 3 most common causes of trauma in pregnancy?
#1 MVA (MC cause)
#2 Domestic Violence
#3 Trips/Falls
S/Sx of what?
-
PAINFUL vaginal bleeding in the 3rd trimester
- uterine, abdominal , back pain
- irritable or tender uterus
- Blood loss both fetal and maternal
Placenta Abruptio
Umbilical vessels
block the cervix:
Vasa Previa
Abnormal attachment of placenta
to uterine myometrium, obliterating the basement layer
OB EMERGENCY!
Placenta Accreta
7 Cardinal Movements of Labor:
1. Engagement
2. Flexion
3. Descent
4. Internal Rotation
5. Extension
6. External Rotation & Restitution
7. Explusion
6 Ps of labor:
� Passenger = EFW
� Position: breech, cephalic, transverse, oblique
� Presentation: OA, OP, ROA, etc.
� Power = UCs, frequency and strength
� Passage= maternal pelvis
� Psyche = Mother's emotional state
what supplements should ALL pregnant women be placed on for prenatal care?
what will one of them specifically help to prevent in fetus?
Folic Acid
400-800mcg/d, Iron & Calcium 1000mg/d
neural tube defects
congestion and bluish discoloration of cervix & vulva ~8-12 weeks gestation:
Chadwick's sign
what are some skin changes that occur throughout pregnancy?
-Melasma ("mask of pregnancy"_
-Linea Nigra
-Darkened areolas
-striae
- spider angiomata
what are 2 methods to estimate date of delivery (EDD)?
-Naegele's rule
-Crown Rump Length (CRL) - most accurate
# of times pregnant (regardless of carried to term):
Gravida
# of births (>20wks) including viable & non viable births:
Para
2 stages of Perimenopause:
Stage 1 (early): regular menses w/cycle length changes; FSH may be elevated
Stage 2 (late): amenorrhea >60d ; FSH > 25 Iu/L; may bet hot flashes & sleep disturbances
2 stages of postmenopause:
Stage 1 (early post): 1st 6 years following the final menstrual period
Stage 2 (late post): 6 years after the final menstrual period until death.
how long does perimenopause typically last?
4-10 years
(ends when menopause starts)
Test to Assess fetal response to the "stress" of contractions:
Contraction Stress Test
need 3 contractions of 40s in a 10min period
stimulate with pitocin or nipple stimulation
Fetal HR Monitoring is also known as what?
Non-Stress Testing (NST)
When would you order a
fetal fibronectin
?
preterm labor
it's a protein secreted when cervix begins to separate away from the amnion
oNegative: likelihood is < 5% that the patient will deliver in the next 2 weeks
o
Positive: 50/50 chance that the patient will deliver in the next 2 weeks
Sudden expulsion of sac and fetus between 18th and 32nd weeks:
Incompetent Cervix
US: shortening & funneling of cervical canal
Incompetent Cervix
what are tx options for Incompetent Cervix?
-
Cervical Cerclage
(purse-string suture around cervix to close)
-Makena (17-OH progesterone)
-Progesterone Suppositories (Crinone)
fever of >100.4 or >38 on any two of the 1st 10 days postpartum:
Postpartum Fever
what is the cause of a postpartum fever?
sx site infection (episiotomy or c-section)
the "turtle sign" is diagnostic for which condition?
shoulder dystocia
what are some serious fetal risks associated with shoulder dystocia?
�
Erb-Duchenne palsy
y*: "Waiter's tip"
� Pneumothorax
�
Hypoxemia ? Fetal death
what is given for GBS prophylaxis?
�
Ampicillin q4hr until delivery
� Clindamycin if PCN allergic
� Vancomycin
BP in
mild
Preeclampsia/eclampsia?
BP in
severe
Preeclampsia/eclampsia?
Mild: BP >140/90
Severe: BP >160/110
what are the benefits of breastfeeding > bottle feeding?
- helps prime infants immune system
- decreases risk of allergies
- higher IQ
- decreases risk of breast, uterine & cervical CA in mother
what is the 1st milk produced from a mother called?
Colostrum - a thick, yellowish milk very high in calories & immune factors
what is the recommendation for breastfeeding?
exclusively breastfeed for the 1st 6 months
when would you use the progesterone challenge test?
Evaluation of secondary amenorrhea
positive response is
any bleeding more than light spotting that occurs within 2 weeks after the progestin is given.
This bleeding will usually occur 2-7 days after the progestin is finished.
when would you see a "ring of fire" appearance on US?
ectopic pregnancy
what is a treatment option for
recurrent
candidiasis of breast or vagina?
Boric Acid or Gentian Violet topically
when would you use the Kleihauer-Betke test?
after
trauma in pregnancy
to determine a maternal/fetal hemorrage
this test measures the amount of Hgb transferred from a fetus to a mother's bloodstream.
Apgar score:
what is the most critical time for physiologic changes to occur for mother & newborn?
The hour after birth.
Changes like maternal fluid shifts, hemorrhage, retained placenta, and fetal lung cardiovascular transitions
what is the average gestational age TO DELIVER twins vs single pregnancy?
twins = 36-37 weeks
single = 40-42 weeks
criteria for fetal distress on FHR monitoring/NST:
-absence of baseline variability
AND
1. either bradycardia (FHR<110)
OR
2. recurrent variable or late decelerations
which type of fetal monitoring is contraindicated in an HIV+ mother in labor?
fetal scalp electrodes
because it increases the risk of vertical transmission of HIV to the infant
What is the dosing schedule for the HPV vaccine series?
The vaccines are administered in a three-dose schedule.
The 2nd dose is administered 1-2mo after the first dose
The 3rd dose is administered 6mo after the first dose.
low values in all 3 parts of the triple screening (AFP, hCG, estradiol) indicate which condition may be present?
trisomy 18 (Edward's syndrome)
what can improve amenorrhea in a pt with PCOS?
progesterone administration
another term for the changes that happen to the renal system in preeclampsia:
Glomeruloendotheliosis
inflammation of the endothelium and of the glomeruli, which leads to endothelial leaking.
what is the best birth control option for a breastfeeding mother?
progestin-only birth control
Septic arthritis in adults younger than 30 years is usually caused by what organism?
Neisseria Gonorrhea
what is the difference in pt presentation between ovarian torsion and ruptured ovarian cyst?
both will present with extreme sudden onset of pain +/-N/V but ovarian torsion will have an enlarged palpable mass where a cyst will not
What is the most common of the ovarian epithelial malignancies?
1.
serous (50%)
2. mucinous (25%)
3. endometrioid (15%)
4. clear cell (5%)
5. transitional cell
How is Naegel's rule calculated for EDD?
LMP - 3mo + 7d + 1yr
what natural supplement can be helpful in menopause?
how about in PMS?
menopause =
black cohish
PMS =
evening primrose oil
what are the 3 phases of puerperium?
Immediate = first 24 hrs after delivery
- Involution begins
-
Lochia Rubra
0-3d
Early = 2nd day to end of 1st week postpartum
-Uterus is regaining muscle tone, decreasing size & descending toward normal position in the pelvis
-
Lochia Serosa
4-10d
Late/Re
After delivery, uterus turns inside out
; top of
fundus passed through cervix & is situated in
vagina or at introitus
usually accompanied by sudden & severe hemorrhage
what is the tx for this?
Uterine Inversion
manual manipulation back into position or surgical
how many cm dilated is a woman at the END of stage 1 labor?
10cm fully dilated
Opening of the uterine wall exposing the uterine
cavity to abdominal cavity; causes significant maternal (& fetal) morbidity & mortality
uterine rupture
what is done for prevention of post partum mood disorders?
Early & frequent assessments in the first 28
days and with the 6-8 wk PP visit - employ
the Depression Scales
what is the MC cause of coagulopathy in pregnancy?
Placenta Abruptio
at what age should you begin screening for breast CA?
when should you stop screening?
What are the guidelines for a women with BRCA1/2?
Begin
annual screening at 40yo
Stop when patient has
life expectancy < 8 years
Annual Breast MRI starting before the age of the youngest relative at time of diagnosis
What should the BIRADS report include?
� Indication for exam
� Breast composition (density)
� Important findings
� Comparison to prior exams/studies
� Assessment
� Management recommendations
which imaging modality is best to detect intracapsular rupture�"Linguine Sign" in a pt with implants?
MRI
which test is used to evaluate nipple discharge after standard mammogram?
ductogrophy
what type of biopsy is preferred in evaluation of breast CA?
Core needle bx
Types of Breast CA:
Premalignant lesions:
-Atypical hyperplasia
-DCIS (Ductal Carcinoma In Situ)
-LCIS (Lobular Carcinoma In Situ)
Invasive CA:
-Infiltrating ductal (MC; 60-70%)
-Infiltrating lobular (10-15%) - common to have bilateral
-Inflammatory/Paget Dz (6%) - skin chan
what is the best test to do for Paget's Dz & Inflammatory Breast CA ("peau d'orange")?
Punch Bx
which hormone produced by the placenta will inhibit milk synthesis during pregnancy?
progesterone
A drop in progesterone will occur with delivery & allow the breast to fully respond to the surge of prolactin
How often should a mother be nursing in the 1st 2 weeks after delivery?
how many wet & soiled diapers = good intake?
8-12x in 24 hrs
should produce 6+ wet diapers & 2+ soiled diapers each day
S/Sx of what?
Symptoms in the baby:
� Struggle during initial letdown
� Rapid weight gain
� Excessive gas and explosive green stools
� Usually refused second breast
� Baby may start refusing to nurse on breast with larger supply
Symptoms in mother:
� Brea
Demand and Supply Mismatch (over supply):
What are tx options for Demand and Supply Mismatch (over supply)?
Behavioral Strategies:
Block feeding
Decrease or
stop pumping
Incorporate massage
Adjust position
Medication:
Pseudoephedrine
Estrogen containing OCPs
Herbals
What are tx options for engorgement?
Frequent nursing
Anti-inflammatories (ibuprofen)
Warm showers
Comfortable, non-restrictive bra
Areolar softening
Alternate positions
Cabbage leaves
What are tx options for milk blebs?
Warm compresses
Lanolin
Sterile deroofing procedure
(with a needle)
what can be done to treat nipple inversion?
if baby is nursing well, don't need to do anything
-breast shells prior to delivery
-syringe method (plunge nipple out)
which specific pain medications should be avoided while breastfeeding?
Codeine & Tramadol
Mucinous retention cysts or epithelial inclusion cysts:
Nabothian Cysts
Not typically treated
what is the MC type of congenital uterine abnormality?
-
Septate Uterus 90%
-Bicornate Uterus 5%
-Didelphic Uterus 5%
-abnormal thickening of uterus lining
-Precursor to adenocarcinoma of the uterus
-Caused by excess estrogen without progesterone
Endometrial Intraepithelial Neoplasia (Endometrial Hyperplasia)
Tx options for Endometrial Hyperplasia:
-Systemic or local
progestin therapy
-Counsel on lifestyle changes�
weight loss, smoking cessation, etc.
-
Total hysterectomy +/- salpingoophorectomy with peritoneal washing
(if patient is done with childbearing)
Grading of Episiotomy tears
what is newborn secretion of milk due to the residual effect of maternal hormones called?
Witch's Milk
what is the legal gestational age cutoff?
23 weeks 5 days
At what age can a minor can get contraception, abortion, be treated for pregnancy
without parental consent
?
>12 yo
California Minor Consent Laws
which condition is known as the "itch that rashes"?
lichen simplex chronicus
what are the risks to the fetus with gestational diabetis?
-macrosomia
-congenital anomalies
-spontaneous abortion
-IUGR
-polyhydramnios
deliver at or before 40weeks
when would you start kick counts?
28weeks ; should have 10 movements within an hour 1x/d
-if <10, drink something cold & sugary, lie on L side, count a second hour
-if still <10 --> L&D immediately
what are early decelerations on NST a sign of?
late?
variable?
early = head compression
late = stressed fetus
variable = cord compression or oligohydramnios
Scoring in Biophysical Fetal Profile:
�
8-10 = reassuring
� 6 = equivocal, repeat in 24 hours
�
<4 = non-reassuring
what are tx options for vulvar psoriasis?
-UV light therapy
-topical steroids
Stages of Labor:
� 1st Stage: may last hours to days ;
beginning of contractions to 10 cm dilation
� 2nd Stage: Fully dilated, the
delivery of baby
� 3rd Stage: may take up to 30 minutes ;
delivering the placenta
� 4th Stage:
2 hours postpartum
� highest risk for PP hemor
what is the tx for HPV?
-
Imiquimod or Podofilox
-Cryotherapy
-Trichloroacetic acid
-Surgical Removal
-Laser therapy
-Cautery
MAY SPONTANEOUSLY RESOLVE WITHIN 8MO
S/Sx of what?
- soft, fleshy, painless growths, typically symmetrical
- single or multiple "cauliflower lesions" found in the genital region or oral cavity
- condyloma acuminata
- cervical dysplasia
HPV
HPV vaccination recommendations/schedule
� 2 doses if started between ages 9 and 14 yo
� 3 doses if started 15 or later or immunocomprised
OLD 3 DOSE FORMAT:
2nd dose, 1 to 2 mo after initial; 3rd dose, 6 mo after initial dose
NEW 2 DOSE FORMAT
(9valent vaccine): initial dose given before the 15
what is the only imaging modality that reliably shows the fallopian tubes & used in Essure (permanent BC) placement?
Hysterosalpingogram (HSG)
At what point would you need to discontinue an operative delivery?
- >2 pop offs
- >3 UCs
- if no obvious descent with each attempt
what qualifies as a "reactive" NST?
FHR acceleration 15 bpm above baseline for at least 15 sec x2 in 20 min interval
what is the difference between variable & variability on NST?
Variability
= beat to beat variance in the FHR baseline�indicates neurological well-being
Variable
= deceleration, usually variable in shape and variable in timing
what qualifies as a normal contraction stress test?
3 UCs of 40 seconds for a duration of 10
induce with nipple stimulation or pitocin
�
IUP with no fetal cardiac activity (FCA)
)*
�Determined by decline in quantitative hCG
�+/- bleeding, +/- cramping
�Body has not recognized as yet that the pregnancy is not growing
Missed abortion
�
Active bleeding, often passing clots and products of conception (POC) at cervical os
s*
�Significant pain/cramping
incomplete abortion
Which immunizations should be given postpartum?
-Rubella (ok w/breastfeeding NOT OK in pregnancy)
-Tdap
-RhoGAM (anti-immunoglobin D)
Bleeding, empty uterine cavity on US, cramping usually is subsided
US findings
o Empty uterus
o Narrow EEopenC
Pelvic exam
o Blood/clots in vault
o Os closed or
Spontaneous/Complete Abortion
S/Sx of what?
�Excessive bleeding/lochia rubra
�
Foul-smelling lochia
�Fever, chills
�Pelvic or back pain
�
Delay with uterine height with boggy, soft, tender uterus
Subinvolution
infection of the uterus following childbirth:
endometritis
prophylactic abx given 60min prior to C-section can reduce risk
S/Sx of what?
�Unilateral or bilateral lower abdominal pain
�
F/Cs
s*, malaise, anorexia, pallor, tachycardia
�
Foul-smelling lochia
a*
�
Tender, large, and boggy uterus
�
Leukocytosis
�Parametria or Pelvic abscess
Endometritis
Tx for uterine inversion?
Requires relaxing uterus for manual manipulation back in to position or surgical replacement
S/Sx of what?
-acute abdominal pain
-change in uterine contour
-change in maternal vital signs/hemodynamic status
-change in FHT
-loss of fetal station
Uterine Rupture
what is Friedman's curve?
How long should it take?
average rate of dilation in labor
should be ~1cm/hr