OB/GYN USMLE World

LAPAROSCOPY

US and CT inadequate b/c unable to reliably demonstrate endometriomas and adhesions.

1. fundal or bimanual massage/uterotonic agent (oxytoicin) to cause contraction of myometrial fibers and retraction of myometrial blood vessels.
2. IV access
3. crystalloid infusion to keep SBP > 90 mmHg
4. notification of blood bank for PRBC

Delivery = most definitive treatment, but delivery < 37 weeks can cause harm to the fetus.

If delivery of the fetus would cause harm that is greater than continuing the pregnancy, monitor and bed rest.

Conversion of adrenal androgens to estrogens by adipose tissue via aromatase

High circulating levels of prolactin have inhib effect on the production of GnRH. LH and FSH suppressed = no ovulation.

In utero, the placenta will not be able to make estrogens, leading to masculinization of the mother that resolves after delivery.

High levels of gestational androgens result in virilized Xx child.

Anogenital discomfort including pruritis,dyspareunia, dysuria, and painful defecation. PE shows porcelain-white polygonal macules and patches with an atrophic "cigarette paper" wuality. Sclerosus and scarring can lead to obliteration of the labia minora and clitoris and a decrease in the diameter of the intriotus.

Amniotic fluid sampling for L/S ratio.

Administer bethamethasone. Tocolytics only indicated with uterine contractions.

Antibiotics in PPROM leads to longer latency period prior to onset of labor. Ampicillin with or without erythromycin may be indicated.

(physical exam + US)
1. No ovarian masses --> ab ct to r/o adrenal mass

2. Bilateral cystic ovaries --> thea lutein cysts (r/o high b-hCG states)

3. Bilateral solid --> mostly pregnany luteoma

4. Unlateral solid --> surgical exploration

bilateral, multinodular, solid masses on both ovaries. characterized by replacement of the normal ovarian parenchyma by solid proliferation of luteinized stromal cells under the influence of hCG. Often asymptomatic but 1/3 of patients develop symptoms of hirsutism and virilization. Bning, self-limited.

abnormal GnRH secretion that stimulates the pituitary to secrete excessive LH and insufficient FSH. Excess LH stimulates excess androgen production by ovarian theca cells resulting in hirsutism, male escutcheeon, acne, and androgenic alopecia.

Anovulation is caused in part by the imbalances in LH and FSH production and in part by insulin resistance.

reassurance and U/S in one week.

bed rest and abstaining from intercourse recommended though not proven to be effective

primary dysmenorrhea -- release of prostaglandins during breakdown of endometrium.

hypercoagulability
history of DVT

Centrilobular necrosis
Hematoma formation
Formation of thrombi in portal capillary system

= swelling of liver with distention of the hepatic capsule

multiparity
advanced maternal age
prior C sec
smoking
multiple gestation
prior placenta previa

== painless vaginal bleeding

vasa previa = fetal blood vessels cross the fetal membranes in the lower segment of the uterus b/w the fetus and the internal crvical os. Also presents as painless antepartum bleeding but is a/w rapid deterioration of the fetal heart tracing, signifying hemorrhage of fetal origin.

Rh+ fetal blood enters maternal blood. Production of anti-Rh IgG antibodies to pass through placenta and cause fetal hemolysis. Manifests as fetal CHF and hydrops fetalis in severe cases.

Administration of RhoGAM (anti-D gamma globulin) prevents isoimmunization by binding the D antigens on fetal blood in maternal circulation, thereby preventing maternal immune system from reacting to them.

When mother is not sensitized or has a weak titer ( > 1:4). < 1:6 is already too late. close monitoring necessary.

at 28 weeks

within 72 hours of any procedure or incident where there is a chanve of feto-maternal blood mixing.

1. thin, grey-white vaginal discharge
2. vaginal pH > 4.5
3. A positive "whiff" test upon addition of KOH to the vaginal discharge
4. "clue cells" (vaginal epithelial cells with adherent coccobacilli on wet mount

3/4 criteria

clusters of pink or skin-colored lesions with a smooth, teardrop appearance.

Small lesions -- trichloroacetic acid or podophyllin.

Larger lesions -- excision or fulguration (electric current)

Mild -- iron supplementation

Moderate and no active bleeding -- iron + progestin

Moderate and active bleeding/severe -- high dose estrogen indicated

inhibited by dopamine and stimulated by serotonin and TRH, ergo hypothyroidism may result in amenorrhea and galactorrhea.

variable deceleration -- abrupt decrease n FHR below baseline whose onset, depth, and duration vary with contraction.

Posible causes:
- cord compression
- low amniotic fluid
- fetal hypoxia

clear cell adenocarcinoma
cervical hypoplasia
uterine malformations (t shape/small)
vaginal adenosis
vaginal septae

Intense ab pain and vaginal bleeding.

Hyperventilation, agitation, tachycardia indicate imminent rupture

After rupture has occurred, patient may feel slightly relieved, but soon after, diffuse pain.

1. b-hCG?

NOT PREGNANT
2. Elevated FSH? Ovarian failure
3. Elevated testosterone? Suspect PCOS
4. TSH high, low T4? hypothyroidism
5. elevated prolactin?
- normal TSH, no prolactin-elevating medications, normal Cr
--> MRI brain with pituitary focus

6. history of uterine procedures and normal FSH, prolactin, TSH? DO AN ESTOGEN/PROGESTIN stimulation test. If there is no withdrawal bleeding, hysteroscopy and/or hysterosalpingogram to rule out Asherman's syndrome (intrauterine adhesions)

antipsychotics
TCA
MAO inhibitors

First Stage
- onset of true labor to full cervical dilation
- < 20 hrs in nulli, <14 hrs in multi

Latent Phase
- from 0 - 3/4cm dilation
- highly variable

Active phase
- from 3/4cm to 10 cm
- >1 cm/hr in nulli, >1.2 cm/hr in mutli

Second Phase
- from full dilation to birth of the baby
- 30 min - 3 hrs in nulli, 5-30 min in multi

Third Stage
- delivery of the baby to delivery of the placenta
- 0-30 min

1. Power (poor contractions, epidural anesthesia)
2. Passenger (baby -- macro, malpresentation)
3. Passage (pelvis -- cephalopelvic disproportion)

prior placental abruption
chronic HTN/HTN
cocaine
alcohol or tobacco use
vascular disease (DM, SLE)

US because the most common cause is inaccurate dating

75 and 90 mg/dL

risk of miscarriage, abnormally large size, congenital malformation, preterm birth, pyelonephritis, preeclampsia, meconium aspiration and still birth, stillbirth

macrosomnia, hypocalcemia, hypoglycemia, hyperviscosity due to polycythemia, respiratory difficulties, cardiomyopathy, CHF

1. Immediate
- perforation
- bleeding

2. Late
- infection
- scarring (asherman's)

Obstetrical indications or when there is rapid deterioration of the state of either mother or fetus and labor is in an early stage such that vag delivery is not emergently possible

Delivery is the definitve treatment of HELLP syndrome in women beyond 34 weeks gestation, when the fetal lungs are mature, or in the presence of signs of fetal or maternal deterioration.

For preg < 34 weeks, epends on state of both mother and fetus. Any deteriortation requires stabilization and delivery, but if fetal well-being is ascertained and the mother is stabilized, dexameth Tx and delivery at 34 weeks.

chemotherapy
radiation
autoimmune ovarian failure
Turner's syndrome
fragile X syndrome

low grade fever and leukocytosis; intrapartum and postpartum chills.

bloody vaginal discharge (normal lochia rubra) that after 3-4 days the color becomes pale and the discharge (lochia serosa), eventually turns white or yellow (lochia alba). If foul smeling, suspect endometritis.

Hemolytic disease of the newborn -- group O mom with group A/B baby. The A and B antigens are antigenic and cause the mother to form IgG antibodies to A or B that can cross the placenta (can also form some IgM antibodies).

Only IgG can cross the placenta, but carying titer levels result in HDN, which is mild in most patients, with neonatal jaundice successfully treated with phototherapy.

ABO incompatibility reactions can occur in the first pregnany b/c both A and B antigens are found in food and bacteria in the environment. These antigens cn induce various degrees of antibody production in grou O indiv.

congenital absense of GnRH secretion (hypogonadotropic hypoganadism) a/w anosmia.

Patients have a normal XX genotype and normalfemale internal reproductive organs. They present with amenorrhea and absent secondary characteristics, such as breast development and pubic hair.

Abnormal deelopment of olfactory bulbs.

Severe form of vomiting (1% pregnancies) b/w 4-10 weeks.

Other severe causes of vomiting must be considerest, wuch as gestational trophoblastic disease (hydratidaform mole, choriocarcinoma). Check b-hCG for markedly elevated levels.

DD includes pyelonephritis, GTD, gastroenteritis, hepatobiliary disease.

Milk increase in ALT, AST, bilirubin, amylase, and lipase are seen in up to 50% of hospitalized patients.

Clindamycin (anarobes) and gentamycin (gram neg)

b/c polymicrobial infection

Can reslt from infection of retained POC in the case of missed, incokmplete, inevitable, or elective abortions. Characterized by fever, chills, abdominal pain and a bloody/purulent dischage.

Broad spec AB are given immediatly after obtaining the blood and cervical/endometial cultures. Immediate surgical evac with gentle suction curettage.

Fasting > 95
1 hr > 180
2 hr > 155
3 hr > 140

In the presence of decreased fetal movements, fetal compromise should be suspected and the best next step in management is NST, carried out by recording the fetal HR while monitoring for spontaneous perceived fetal movements. Normal if in 20 min, 2 fetal HR accelerations of at least 15 bpm above baseline level lasting at least 15 s each.

If less than 2 accelerations are noted, abnormal. Most common cause of nonreactive NST is sleeping baby.

Scoring system to eval fetal well being:

NST
fetal tone (flexion or extension of extremity)
fetal movements
fetal breathing movements (at least 20 s in 30 min)
amniotic fluid volume (single pocket > 2cm in vertical axis)

8-10 NORMAL

8 + decrease AF
FETAL COMPROMISE
delivery should be considered

6 w/o oligohydramnois
delivery should be considered > 37 weeks

<37 weeks, BPP should be repeated in 24 hours and delivery should be done if not improved

6 w/oligohydramnoin
> 32 weeks delivery
< 32 weeks daily monitoring

< 4
> 26 weeks delivery is indicated

chromosomal abnormalities
congenital abnorm
congenital infxn (TORCH)

maternal hypertension
preeclampsia
uterina anomalies
APPLA
collagen vascular disease
smoking

Screening: VDRL, RPR

Confirmation: FTA-ABS (serologic), darkfield microscopy

delivery at < 37 weels

duration of membrane rupture > 18 hours

GBS bacteruria in any concentration during current pregnancy

Prior history of delivery of an infant with GBS sepsis

in many, the circulating levels of thyroid stimulating immunoglobulin remain as high as 500 times the normal value for several months following thyroidectomy. These IgG autoantibodies cross the placenta and can cause thyrotoxicosis in the fetus and the neonate by directly stimulating the detal thyroid gland. Neonatal thyrotoxicosis is an uncommon clinical entitiy characterized by goiter, tachypnea, tachycardia, cardiomegaly, restlessnes, diarrgea and poor weight gain in the infant typically w/i 1-2 days following delivery.

Immaturity of the developing hypothalamic-pituitary-gonadal axis that does not produce adequate quantities and proportions of the hormones (i.e. H and FSH) required to induce ovulation. In the absence of ovulation, menstrual cycles lack their regular periodicity. The endometrium builds up under the influence of estrogen, but without the inflence of progesterone, the cue to slough the endometrium is lacking and mestrual-like bleeding occurs due to estrogen breakthough bleeding. normaly, pogesterne is produced in increased amounts by the corput luteum following ovlation, and withdrawal of this progesterone as the corpus luteum degenerates results in menses.

No.

Sudden onset of ab pain in the third trimester and no vaginal bleeding? Some cases of bleeding may be retroplacental.

HRT affects the metabolism of thyroid hormones. In patients who take thyroxine, for example, will have a greater requirement.

in a singleton pregnancy, prompt delivery.

Retained POC can result in hypofibrinogenemia and coagulopathy. Low fibrinogen and thrombocytopenia are cause of concern for DIC.

Discuss options for delivery.

TVUS

look for presence of funneling of the cervix or shortening of the cervical length. Length should be more than 25 mm at 24 weeks. A cervical length below the 10th percentile for GA is considered short cervix

The appearance of proteinuria during pregnancy may represent lupus nephritis, preeclampsia or both. Signs that favor lupus as the origin of the proteinuria include a rapid aggravation of the proteinuria, associated clinical signs of active SLE, and the presence of RBC casts in the urinalysis which indicate true nephritis rather than simple protein loss. If proteinuria persists after delivery, renal biopsy is then indicated.

1. Premenopausal?
COLPOSCOPY

2. Postmenopausal?
a) colposcopy
b) HPV testing
c) repeat Pap at 6-12 mo

HPV negative? routine screening
HPV positive? colopscopy

Repeat Paps abnormal? colposcopy
Normal? routine sreening

depends on GA of fetus and severity of bleeding.

If mother is stable and the fetus is at term, schedules C se.

Until C se performed monitor!

If preg is not yet term and the mother is stable, expectant management with close monitoring. At 36 weeks, asses lung maturity. If mature, elective c-sec.

breakthrough bleeding
amenorrhea
HTN
venous thromboembolic disease
decreased risk of ovarianand endometrial cancer
increased risk of cervical cancer
liver disorders

1. cervical cytology
2. Rhesus type and antibody
3. hematocrit,hemoglobin,and MCV
4. rubella immunity
5. varicella immunity
6. urine culture
7. syphillis testing
8. HBV antigen
9. chlamydia testing
10. HIV test
11. influenza vacine during flu season
12. offer genetic screening for cystic fibrosis
13. Down syndrome testing

simple 1%

complex 3%

Simple atypical 8%

complex atypical 29%

penny, nickel, dime, quarter

cyclic progestins

otherwise, atypia? in woman who want to preserve fertility, try cyclic progestins then repeat biopsy in 3-6 mo.

Hysterectomy otherwise

Supportive

cysitis, acute pyelonephritis, pretermbirth, and increased perinatal mortality.

Accepted regimens include nitrofurantoin, amoxicillin, or first gn ceph for 7 days.

Modifiable? low estrogen, malnutrition,decreased Ca,decreased vit D, use of steroids, immobility, cigarette,alchohol

Non-modifiable: female, advanced age,small body size, late menarche/early menopause, Cauc/Asian,fam history

profuse ivory to gray malodorous discharge with a pH of 5 to 6.5.

Fish odor uon addition of KOH.

Itching and burning not usual.no inflammation of vaginal epithelium and cervix.

the majority of breech presentation will self-correct by the 37th week of gestation. Any attempt to convert is not indicated before the 37th week.

dysmenorrheea
heavy menses
enlarged uterus

submucosal fibroids often interfere with implantation of the embryo,resulting in infrtility.

Presence of endometrial glands in the uterine muscle. This invasion can extend through the full thickness of the myometrium and in some instances to the srosa of the utrus. It occurs most frquently in women above 40 and typically presents with severe dysmenorrhea and menorrhagia.

For women above 35, perform endometrial curettage to r/o endometrialcarcinoma.

Adeno -- enlarged, generally symmetrical uterus

Leio -- can aslo present with dysmen, menorrha, large uterus BUT usually irregularly shaped

35-37 weels

DM type I

Hashimoto

Addison

pernicious anemia

High fever

failure to respond to oral antibiotics
inability to take oral medications (nausea, vomiting)

pregnancy

noncompliance

> 35

obese

chronically hypertensive

diabetic

cord compression

coagulation profile should be drawn to detect incipient DIC. Retention of a dead fetus may cause a chronic consumptive coagulopathy due to gradual relase of tissue factor (thromboplastin) from the placenta into the maternal circulation. Fibrinogen values in the low/normal rangle may be an early sign of consumptive coagulopathy, especially if there is an associated decrease in PLT count, increase in PT and PTT or the presence of fibrin split products.

If coagulation parameters are normal, the management decision will depend on the patient's preference: the option ar ither watchful expectancy or induction of labor. 80% of cases spontaneously abort w/i 2-3 weeks. Increased risk of chorioamnionitis and DIC.

(ruptured umbilical vessel)

antepartum hemorrhage with very characteristic fetal heart changes progressing from tachycardia to bradycardia to a sinusoidal pattern. If fetal bleeding is suspected, perform Apt test -- which differentiates maternal from fetal blood-- can be performed to confirm the diagnosis.

Vasa precia is a rare condition in which the fetal blood vessels traverse the fetal membranes across the lower segment of the utrus b/w the baby and the internal cervical os (velamentou cord inertion).

1. All RhD neg pred women should undergo an antibody screen at the first prenatal visit and again at 28 wks gestation.

2. At 28 weeks, a 300 mcg prophylactic dose of antiD globulin is administered

3. A 300 mcg prophylactic dose of RhoGAN is administered when there is an increased risk of fetomaternal hemorrhage (miscarriage, abortion, ectopic, amniocen, CVS, trauma, external cephalic version, antepartum bleeding, fetal death)

4. RhoGAM should be administered within 72 hours of delivery of an RhD pos infant. A standard dose of 300 mcg is indicated unlss there is concern for fetomaternal hemorrhage (E-rosette test)