BCF: OBGYN

Involuntary loss of urine that is objectively demonstrable and creates social or hygienic concern

Differential dx:
Genuine stress urinary incontinence
Urge incontinence
Overflow incontinence
fistula

Incontinence through the urethra due to sudden increases in intra-abdominal pressure, in the absence of bladder muscle spasm

Bladder neck has fallen out of its normal intra-abdominal position.
Hx: painless loss of urine concurrent with valsalva; no urge to void.
Dx test: PE: loss of bladder angle, cystometric examination
Tx: urethropexy (Burch procedure) to return proximal urethra back to intra-abdominal position

Loss or urine due to an uninhibited and sudden bladder detrusor muscle contraction

Detrusor muscle is overactive and contracts unpredictably
Hx: urge component “have to go to the bathroom and can’t make it there in time”
Dx test: cystometric examination shows uninhibited contractions
Tx: anticholinergic medication to relax detrusor muscle (surgery may worsen)

Loss of urine associated with an overdistended, hypotonic bladder in the absence of detrusor contractions. This condition often is associated with diabetes mellitus, spinal cord injuries, or lower motor neuropathies. May be caused by urethral edema after pelvic surgery.

Overdistended bladder due to hypotonic bladder
Hx: loss of urine with valsalva; dribbling; diabetes or spinal cord injury
Dx test: postvoid residual (catherization) shows large amount of urine
Tx: intermittent self-catherization

Communication between bladder or ureter and vagina
Hx: constant leakage after surgery or prolonged labor
Dx test: dye into bladder shows vaginal discoloration.
Tx: surgical repair of fistulous tract.

Investigation of pressure and volume changes in the bladder with the filling of known volumes. It often is used to discern between GSUI and UUI.

“turning inside out” of the uterus, where upon the fundus of the uterus moves through the cervix into the vagina

Best method for averting a uterine inversion is to await spontaneous separation of the placenta from the uterus before placing traction on the umbilical cord.
Treat with halothane (uterine relaxation for uterine replacement).sometimes can be replaced by using the gloved palm and cupped fingers.
Profuse hemorrhage may follow placental removal.
Even with optimal treatment of uterine inversion, hemorrhage is almost a certainty.

Four signs
1) Gush of blood
2) Lengthening of the cord
3) Globular and firm shape of the uterus
4) Uterus rising up to the anterior abdominal wall

From delivery of infant to delivery of the placenta (upper limit of normal is 30 min)

Third stage of labor that has exceeded 30 min

Point in time in a woman’s life when there is cessation of menses due to follicular atresia occuring after age 40 years (mean age 51 years).

(climacteric)
Transitional 2 to 4 yr period spanning from immediately before to immediately after the menopause.
Symptoms include irregular menses d/t anovulatory cycles; vasomotor symptoms, such as hot flashes and decreased estrogen and androgen levels.
Because ovarian inhibin levels are decreased
FSH levels risk even before estradiol levels fall.
Decreased estradiol concentrations lead to vaginal atrophy, bone loss and vasomotor symptoms.

Irregular unpredictable episodes of increased skin temperature and sweating lasting approximately 3-4 minutes

Cessation of ovarian function due to atresia of follicles prior to age 40 years.
At ages younger than 30 years autoimmune diseases or karyotypic abnormalities should be considered.

Acute febrile illness usually caused by the exotoxin of S. aureus that leads to multiorgan dysfunction.

Fever, rash, and hypotension with involvement of at least three other systems, such as gastrointestinal, muscular, mucous membrane, renal, hepatic, or CNS.

Rash – intense sunburnlike develops during the first 48 hrs and after several days becomes maculopapular, similar to a drug-related rash. After 10 days, the rash typically desquamates, including involvement of the palms and soles.

Copious IV fluids with close monitoring of urine output and blood pressure.

IV nafcillin or methicillin usually is the best antibiotic therapy; when the diagnosis is unclear, an aminoglycoside agent often is added for gram negative coverage.

Dopamine or dobutamine sometimes required when fluids alone are insufficient to maintain BP.

Rarely a toxic shock like picture may be caused by other organisms, such as group A beta-hemolytic streptococcus.

[(2 x diastolic blood pressure) + (1 x systolic blood pressure)]/3

Cervical change accompanied by regular uterine contractions.

Stages of labor: first stage – onset of labor to complete dilation of cervix, second stage – complete cervical dilation to delivery of infant. Third stage – delivery of infant to delivery of placenta

Latent phase
Active phase
Protraction of active phase
Arrest of active phages

Initial part of labor during which the cervix mainly effaces (thins) rather than dilates (usually cervical dilation <4 cm)

Portion of labor during which dilation occurs more rapidly (usually cervical dilation > 4 cm)

Cervical dilation in the active phase that is less than expected (normal greater than or equal 1.2 cm/hr for a nulliparous women and greater than or equal to 1.5 cm/hr for a woman who has had at least one vaginal delivery.

No progress in the active phase of labor for 2 hr.

Pregnancy with vaginal spotting during the first half of pregnancy. This does not delineate the viability of the pregnancy.

Pregnancy outside of the normal uterine implantation site. Most times this means a pregnancy in the fallopian tube.

Glycoprotein that is secreted by the chorionic villi of a pregnancy. It is the hormone upon which pregnancy tests are based. The normal pregnancy will have a logarithmic rise in early pregnancy. Usually the beta subunit is assayed to prevent cross-reactivity with luteinizing hormone.

Level of serum hCG such that an intrauterine pregnancy should be seen on ultrasound. For endovaginal sonography, this level is 1500 to 2000 mIU/mL. When an intrauterine pregnancy is not seen on sonography and the hCG level exceeds the threshold, then it is highly probably that the pregnancy is ectopic.

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

placenta previa,
implantation over the lower uterine segment,
prior cesarean scar or other uterine scar,
uterine curettage,
down syndrome

Abnormally implanted placenta penetrates into the myometrium.

Abnormally implanted placenta penetrates entirely through the myometrium to the serosa.

Yellow exudative discharge arising from the endocervix with 10 or more polymorphonucleocytes per high-power field on microscopy.

C. trachomatis most common organism implicated.
Gonorrhea may also be a pathogen.

Lower: vulva, vagina and cervix

Upper: uterine corpus, fallopian tubes, and ovaries

Pregnancy less than 20 weeks’ gestation associated with vaginal bleeding, generally without cervical dilation.

Hx: vaginal bleeding.
No passage of tissue.
Closed cervical os.
Uncertain viability of pregnancy – 50% will miscarry
Treatment: transvaginal ultrasound and hCG levels

Pregnancy less than 20 weeks’ gestation associated with cramping, bleeding, and cervical dilation; there is no passage of tissue.

Hx: cramping and bleeding
No passage of tissue
Open cervical os
Abortion is inevitable
Tx: D&C vs. expectant managment

Pregnancy less than 20 weeks’ gestation associated with cramping, vaginal bleeding, an open cervical os, and some passage of tissue per vagina but also some retained tissue in utero. The cervix remains open due to the continued uterine contractions; the uterus continues to contract in an effort to expel the retained tissue.

Hx: cramping, bleeding (still continuing)
Some but not all tissue passed.
Open cervical os
Nonviable pregnancy
Tx: D&C

Pregnancy less than 20 weeks’ gestation in which all the products of conception have passed; the cervix is generally closed. Because all the tissue has passed, the uterus no longer contracts, and the cervix closes.

Hx: cramping, bleeding previously but now subsided
All tissue passed
Closed cervical os
Nonviable pregnancy
Tx: follow hCG levels to negative

Pregnancy less than 20 weeks’ gestation with embryonic or fetal demise but no symptoms such as bleeding or cramping.

Hx: no symptoms
No passage of tissue
Closed cervical os.
Nonviable pregnancy (diagnosed on ultrasound)
Tx: D&C vs. expectant management.

Inability of the fetal shoulder to deliver spontaneously, usually due to impaction of the anterior should behind the maternal symphysis pubis.

Should be suspected with fetal macrosomia, maternal obesity, prolonged second stage of labor and gestational diabetes.
Significant fetal hypoxia may occur with undue delay from the delivery of the head to the body.
Excessive traction on the fetal head may lead to a brachial plexus injury to the baby.
Fundal pressure should be avoided because of increased neonatal injury.

For shoulder dystocia

Maternal thighs are sharply flexed against the maternal abdomen to straighten the sacrum relative tot the lumbar spine and rotate the symphysis pubis anteriorly toward the maternal head.

For shoulder dystocia

Operator’s hand is used to push on suprapubic region in a downward or lateral direction in an effort to push the fetal shoulder into an oblique plane and from behind the symphysis pubis.

Brachial plexus injury involving the C5-6 nerve roots, which may result from downward traction of the anterior shoulder; the baby usually has weakness of the deltoid and infraspinatus muscles as well as flexor muscles of the forearm. The arm often hangs limply by the side and is internally rotated.

mcRoberts’ maneuver
suprapubic pressure
wood’s corkscrew maneuver
delivery of the posterior arm
zavanelli maneuver

Attachments of the uterine cervix to the pelvic side walls through which the uterine arteries transverse

(IVP)
Radiologic study in which intravenous dye is injected and radiographs are taken of the kidneys, ureters, and bladder

Dilation of the renal collecting system, which gives evidence of urinary obstruction.

Procedure whereby a scope is placed into the bladder via the urethra. Various procedures, such as placement of stents into the ureters can be performed.

Placement of a stent into the renal pelvis through the skin under radiologic guidance to relieve a urinary obstruction.

Up to 1% of abdominal hysterectomies can be complicated by ureteral injury.
Cancer, extensive adhesions, endometriosis, tubo-ovarian abscess, residual ovaries, and interligamentous leiomyomata are risk factors.

Most common location for ureteral injury is the cardinal ligament, wher the ureter is only 2 to 3 cm lateral to the cervix. The ureter is just under the uterine artery.

Can indicate malignant or premalignant conditions.
Biggest concern endometrial cancer.
Can also be premalignant such as endometrial hyperplasia.
Complex hyperplasia with atypica is associated with endometrial carcinoma in 30-50% of cases.

Approach: endometrial sampling, endometrial polyps, atrophic endometrium, endometrial stipe.

Thin catheter is introduced through the cervix into the uterine cavity under some suction to aspirate endometrial cells.

Growth of endometrial glands and stroma, which projects into the uterine cavity, usually on a stalk; it can cause postmenopausal bleeding.

Most common cause of postmenopausal bleeding is friable tissue of the endometrium or vagina because of low estrogen levels.

Transvaginal sonographic assessment of the endometrial thickness; a thickness greater than 5 mm is abnormal in a postmenopausal woman.

Early menarche
Late menopause
Obesity
Chronic anovulation
Estrogen-secreting ovarian tumors
Ingestion of unopposed estrogen
HTN
DM
Personal or family history of breast or ovarian cancer

Total abdominal hysterectomy, bilateral salpingo-oophorectomy
Omentectomy
Lymph node sampling
Peritoneal washes.

Vaginal bleeding occuring after 20 wks gestation

Placenta completely covers the internal os of the uterine cervix

Placenta partially covers the internal cervical os

Placenta abuts against the internal os of the cervix

Edge of the placenta is within 2-3 cm of the internal cervical os

Premature separation of a normally implanted placenta

Best treatement at a gestational age near term (>34 weeks) is delivery.
As opposed to dx of placenta previa, ultrasound examination is a poor method for assessment of abruption because the freshly developed blood clot behind the placenta has the same sonographic texture as the placenta itself.

Umbilical cord vessels that insert into the membranes with membranes overlying the internal cervical os and thus are vulnerable to fetal exsanguination upon rupture of membranes.

HTN (chronic and preeclampsia)
Cocaine use
Short umbilical cord
Trauma
Uteroplacental insufficiency
Submucous leiomyomata
Sudden uterine decompression (hydramnios)
Cigarette smoking
Preterm premature rupture of membranes

When the bleeding occurs completely behind the placenta and no external bleeding is noted.
Condition is less common than overt hemorrhage but is more dangerous.

Fetal blood enters into the maternal circulation.

More common with placental abruption

Kleihauer-betke test – takes advantages of the different solubilities of maternal versus fetal hemoglobin.

Bleeding into the myometrium of the uterus giving a discolored appearance to the uterine surface

Preinvasive lesions of the cervix with abnormal cellular maturation, nuclear enlargement and atypia.

Removal of the uterus, cervix, and supportive ligaments such as the cardinal ligament, uterosacral ligament and proximal vagina.

Radioactive implants placed near the tumor bed

External-beam radiation where the target is at some distance from the radiation source.

No menses for 6 months.

Anterior pituitary hemorrhagic necrosis caused by hypertrophy of the prolactin-secreting cells in conjuction with a hypotensive episode, usually in the setting of postpartum hemorrhage. Bleeding in the anterior pituitary induces pressure necrosis.

Asherman’s syndrome
Scar tissue that forms in the endometrium, leading to amenorrhea due to unresponsiveness of the endometrial tissue.

Classically defined as defined as bleeding greater than 500 mL for a vaginal delivery and greater than 1000 mL for a cesarean delivery. From a more pathophysiologic standpoint, it is the amount of bleeding that results in, or threatens to result in, hemodynamic instability if left unabated.

Cord prolapse
Baseline fetal heart less than 110 bpm for more than 10 min.

Umbilical cord enters through the cervical os appears in front of the present part.

Maneuver used to cause a rent in the fetal chorioamniotic membranes.

Confirm fetal heart rate (vs. maternal heart rate)
Vaginal examination to assess for cord prolapse
Positional changes
Oxygen
Intravenous fluid bolus
Discontinue oxytocin

Largest transverse (biparietal) diameter of the fetal head has negotiated the bony pelvic inlet.

Nonpuerperal watery or milky breast secretion that contains neither pus nor blood. The secretion can be manifested spontaneously or otained only by breast examination.

Tumor in the pituitary gland that produces prolactin; symptoms include galactorrhea, headache and peripheral vision defect (bitemporal hemianopsia)

Drugs (tranquilizers, tcas, antiHTNs, narcotics, oral contraceptive pills)
Hypothyroidism
Hypothalmic causes (craniopharyngioma, sarcoidosis, histiocytosis, leukemia)
Pituitary causes (microadenoma (<1 cm), macroadenoma (> 1cm)
Hyperplasia of the lactotrophs
Empty sella syndrome
Acromegaly
Renal disease (acute or chronic)
Chest surgery or trauma (breast implants, herpes zoster at the T2 dermatome of the chest)

PUPPP erythematous papules and hives beginning in the abdominal areas and often spreading to the buttocks.
Most likely cause intrahepatic cholestasis, process in which bile stalts are incompletely cleared by the liver, accumulate in the body, and deposited in the dermis. Disorder usually begins in the third trimester.
No associated skin rashes other than excoriations from patient scratching.

Intrahepatic cholestasis of unknown etiology in pregnancy whereby the patient usually complains of pruritis with or without jaundice and no skin rash

Common skin condition of unknown etiology unique to pregnancy, characterized by intense pruritus and erythematous papules on the abdomen and extremities

Rare skin condition seen only in pregnancy, characterized by intense itching and vesicles on the abdomen and extremities

Synonymous with salpingitis (infection of the fallopian tube)

Extreme tenderness when the uterine cervix is manipulated digitally, which suggests salpingitis

Abdominal tenderness
Cervical motion tenderness
Adnexal tenderness
Vaginal discharge
Fever
Pelvic mass of PE or ultrasound

Collection of purulent material within and around the distal tube and ovary, which, unlike the typical abscess, often is treatable by antibiotic therapy rather than surgical drainage.

HSV prodromal symptoms – prior to the outbreak of the classic vesicles, the pt may complain of burning, itching or tingling
Neonatal herpes infection: HSV can cause disseminated infection with major organ involvement; be confined to encephalitis, eyes, skin or mucosa or be asymptomatic.
Acyclovir has activity against both HSV-1 and HSV-2.
Acyclovir reduces viral shedding, pain symptoms and associated with faster healing of the lesions.
Suppressive therapy is reserved for frequent outbreaks.

Smooth muscle, benign tumors, usually of the uterus

Malignant, smooth muscle tumor with numerous mitoses

Leiomyomata that are primarily on the endometrial side of the uterus and imping on the uterine cavity

Leiomyomata that are primarily in the uterine muscle

Leiomyomata that are primarily on the outside of the uterus, on the serosal surface. Physical examination may reveal a ‘knobby’ sensation

Leiomyoma that is on a stalk

Changes of the leiomyomata due to rapid growth; in the center of the fibroid becomes red, causing pain.

Characterized by HTN and proteinuria. Although not a criterion, nondependent edema also is usually present.
Systolic Bpat or higher than 140 mmHg or diastolic BP at or higher than 90 mmHg.
2 elevated blood pressures, measured 6 hrs apart (measurements taken in a seated position).
Proteinuria usually is based on timed urine collection, defined as equal to or greater than 300 mg of protein in 24 hr. facial and hand edema would be considered nondependent edema.

HA, vision changes, seizures, hyperreflexia, blindness
Decreased GFR, proteinuria, oliguria
Pulmonary edema
Thrombocytopenia, microangiopathic anemia, coagulopathy, sever HTN (160/110)
Intrauterine growth restriction, oligohydramnios, decreased uterine perfusion
Increased liver enzymes, subcapsular hematoma, hepatic rupture.

Benign, smooth muscle tumor of the breast, usually occurring in young women.
Core-needle biopsy – use of a 14 to 16 gauge needle to extract tissue from a breast mass, which preserves cellular architecture
FNA – small gauge needle with associated vacuum via a syringe to aspirate fluid or some cells from a breast mass and/or cyst.

Inability to conceive after 1 yr of unprotected intercourse

Primary – women has never been able to get pregnant

Secondary – woman has been pregnant in the past but has 1-yr inability to conceive.

More commonly at 14 weeks’ gestation or after delivery
Unilateral abdominal or pelvic pain
Associated with nausea or vomiting
Treatment: surgery

Salpingitis, particularly with C. trachomatis
Tubal adhesive disease
Infertility
Progesterone-secreting IUD
Tubal surgery
Prior ectopic pregnancy
Ovulation induction
Congential abnormalities of the tube

Cervical change associated with uterine contraction prior to 37 completed weeks and after 20 weeks’ gestation. In a nulliparous woman uterine contractions and a single cervical examination revealing 2-cm dilatation and 80% or greater effacement is sufficient to make the diagnosis

Pharm agents used to delay delivery once preterm labor is diagnosed. The most commonly used agents are magnesium sulfate, terbutaline, ritodrine and indometacin

Betamethasone or dexamethasone given intramuscularly to a pregnant woman in an effort to decrease some of the complications of prematurity, particularly respiratory distress syndrome (intraventricular hemorrhage in the more extremely premature babies)

Bacterial infection of the bladder defined as having greater than 100,000 colony-forming units of a single pathogenic organism on a mid-stream voided specimen

Infection of the urethra commonly caused by C. trachomatis

Urgency and dysuria caused by urethral inflammation of unknown etiology; urine cultures are negative.

2 tabs of Ovral oral contraceptives (total of 0.1 ethinyl estradiol and 0.5 mg levonorgestrel) at time zeron and two tablets after 12 hr.

Progestin only
Levonorgestrel 0.75 mg taken orally at time zero and the same dose after 12 hr.

3-dimensional mass that, on palpation, is felt to be separate from the remainder of the breast tissue.

Benign germ cell tumor that may contain all three germ cell layers

Benign cystic teratoma containing thyroid tissue, which can cause symptoms of hyperthyroidism

Abnormal growth (either benign or malignant) of the ovary; most will not regress

Neoplasm arising form the outer layer of the ovary, which can imitate the other epithelium of the gynecologic or urologic system.
Most common type of ovarian malignancy occuring usually in older women.

Physiologic cysts of the ovary which occur in reproductive-aged women, of follicular, corpus luteal or theca lutein in origin

Germ cell tumors ~25% of all ovarian tumors
Second most frequent type of ovarian neoplasms
Found mainly in young women (20s – 30s)
Most common tumor is the benign cystic teratoma (dermoid)
Presents as a pelvic mass and causes pain due to rapidly enlarging size
60-70% of pts present at stage I, limited to one or both ovaries.

Mature benign cystic teratomas (dermoid cysts) constitute more than 95% of all ovarian teratomas.
Make up 15-25% of all ovarian tumors, especially in 20s- 30s
Most common elements are ectodermal derivatives, such as skin, hair follicles and sebaceous or sweat glands.

Evaluation guided by the suspicion of neoplasm (benign or malignant)
At the extremes of ages, there are few functional ovarian cysts, and the management is straightforward.
Larger than 8 cm likely a tumor.
Smaller than 5 cm suggests a functional cyst
Between 5 – 8 cm, sonographic features may help to distinguish functional ovarian cyst from neoplasm

Condition where scar tissue or synechiae form and obliterate the endometrial cavity, usually because of uterine curettage following a pregnancy

Asherman’s syndrome

Radiologic study in which radiopaque dye is injected into the endometrial cavity via a transcervical catheter; used to evaluate the endometrial cavity and/or patency of the fallopian tubes

Procedure of direct visualization of the endometrial cavity and/or patency of the fallopian tubes.

Assessing the depth and direction of the cervical and uterine cavity with a thin blunt metal probe

(tubal diverticuli)
Condition in which the tubal epithelium penetrates into the muscularis or even the serosa, commonly associated with tubal infection

Tube damage or disease leading to inability to conceive, usually divided into proximal blockage and distal blockage

Procedure whereby dye is injected into the uterus via a transcervical catheter, and tubal patency is assessed by laparoscopy or laparotomy

Operative techniques for repairing tube damage in an attempt to enhance conception rates, which may or may not include microsurgery. Microsurgery uses magnification and fine suture material.

Classically defined as greater than 500 mL blood loss at a vaginal delivery and greater than 1000 mL during a cesarean delivery. Practically speaking, it means signficant bleeding that may result in hemodynamic instability if unabated.

Lack of myometrial contraction, clinically manifested by a boggy uterus

Risk factors: magnesium sulfate, oxytocin used during labor, rapid labor and/or delivery, overdistension of the uterus (macrosomia, multifetal pregnancy, hydramnios), intra-amniotic infection (chorioamnionitis), prolonged labor, high parity

(methergine)
Ergot alkaloid agent that induces myometrial contraction as a treatment of uterine atony, contraindicated in HTN.

Prostaglandin compound that causes smooth muscle contraction, contraindicated in asthmatic patients

Failure of development of ovaries, usually associated with a karyotypic abnormality and often associated with streaked gonads.

Infection of the breast parenchyma typically caused by S. aureus

Presence of a collection of purulent material in the breast, which requires drainage

Noninfected collection of milk due to a blocked mammary duct leading to a palpable mass and symptoms of breast pressure and pain.

(or polyhydramnios)
Excess amniotic fluid.

Hx: irregular menses, obesity
Test: basal body temperature chart, LH surge, or progesterone level
Tx: clomiphene citrate

Hx: uterine fibroids
Test: hysterosalpingogram showing abnormal uterine cavity
Tx: hysteroscopic procedure

Hx: hernia, varicocele, mumps
Test: semen analysis
Tx: repair of hernia or varicocele, in vitro fertilization

Hx: chlamydial or gonococcal infection
Test: hysterosalpingogram
Tx: laparoscopy; in vitro fertilization

Hx: 3 Ds: dysmenorrhea, dyspareunia, dyschezia
Test: laparoscopy (some advocate CA, 125)
Tx: ablation of endometriosis, medical therapy