CSII exam 2

bacterial vaginosis dx

- **amsel criteria: must have at least 3/4 of the following 1. **pH >4.5 2. presence of **clue cells on wet mount 3. **positive whiff test for amine: fishy odor to discharge when a drop of KOH is added 4. **homogeneous, nonviscous, milky white discharge adherent to vaginal walls - **vaginal gram stain is gold standard - DNA probe - FemExam and PIP activity test card: OTC test cards

birth rate and fertility rate

- **birth rate is commonly expressed in terms of the number of live births per 1000 population -**fertility rate is expressed as the number of liver births per 1000 women ages 15-44yo: a more sensitive measure of the reproductive activity of a given population

trichomonas vaginalis

- **most common treatable STD in US - **risk factors: multiple sexual partners, lower socioeconomic status, prior hx of STD, lack of condom use - transmission: **sexually transmitted - may persist for months to years in epithelial crypts and periglandular areas microbiology - **flagellated anaerobic protozoa - **only protozoa to infect genital tract - associated with: **preterm rupture of membranes and preterm delivery - **increased risk of HIV acquisition

Klinefelter's syndrome

- 47 XXY - hyalinized testes - external and internal male genitalia - gynecomastia - small testes, azoospermia, decreased facial and axillary hair, decreased libido, tall stature and increased leg length, decreased penile length, increased risk of breast tumors, thromboembolic disease, learning difficulties, speech delay and decreased verbal IQ, obesity, DM, metabolic syndrome, varicose veins, hypothyroidism, systemic lupus erythematosus, epilepsy

evaluation of sex problems

- 50% of men and women reported experiencing at least 1 sexual problems; less than 20% sought medical assistance - if doc does not ask then we will not know there is a problem - use techniques inclusion, normalization, and universalization to start discussions about sexual problems - models to approach sexual concerns including PLISSIT (permission, limited info, specific suggestions, intensive tx) and ALLOW (ask, legitimize, limitations, open up, and work together)

precocious puberty

- >75% of children investigated for precocious puberty will have a benign dx and considered a normal variation - children with developmental disabilities have a higher incidence of precocity - precocious puberty is classified as **central (GnRH dependent) or **peripheral (nonGnRH dependent)

breast cancer in women statistics

- affects 1/8 american over lifetime - most common cancer in women except skin - second to lung cancer as cause of death

nipple discharge duct ectasia

- benign - u/l or b/l - discharge is often green or brown - mass behind the nipple may be present - nipple retraction may be present

metformin for GDM

- category B - has been shown to cross placenta - in PCOS, metformin is used and usually not discontinued until >8 wks, long after organogenesis - study shows less miscarriages in this group when on metformin - **use metformin if there are barriers to using insulin

insulin for GDM

- considered 1st line in tx for DM in pregnancy - metformin and glyburide are also not FDA approved for the tx of DM in pregnancy - usually added for persistent fasting levels >105 - or added for failed oral management - ***does not cross placenta, pregnancy category B - no insulin regimen has been shown to be more effective, simpler is better insulin requirements will increase - 6-18 wks: .7 units/kg - 18-26 wks: .8 units/kg - 26-36 wks: .9 units/kg - 36-40 wks: 1 units/kg one way to distribute - 25 wks, 220lbs - should use 80 units (.8 units/kg) -2/3: 54 units.... 2/3: 36 units NPH and 1/3: 18 units regular... both 30 min prior to breakfast/ AM dose - 1/3: 26 units.... 1/2: 13 units regular 30 min prior to supper and 1/2: 13 units NPH at 10 pm.... PM dose - NPH is for the 2 hr post prandial glucose, regular for after meals if high BG

premature/ rapid ejaculation

- defined as the occurrence of male ejaculation, usually with orgasm, before desired by the individual, partner, or both - dx is made from hx - tx is based on behavioral techniques - SSRI antidepressants have been used but is off label - addition of PDE5 inhibitors added to SSRIs has shown improvement - topical formulations to decrease sensitivity

combined hormonal contraception

- estrogen progestin - 3 methods currently available: combined oral contraceptive (OC), transdermal patch, vaginal ring - similar mechanisms of action - differences: compliance, ease of use, preference

medications for GDM

- glyburide - metformin - insulin

FRAX/ fracture risk assessment tool

- guidance for BMD testing and tx - provide 10 yr probability of fracture - intended to use in tx naive post menopausal women with no prior hip or vertebral fx - low bone mass: recommended that dexa reports include frax score only if pt's BMD equals low bone mass, tx should be considered, 20% risk of a major osteoporotic fracture in next 10 yrs - osteoporosis: not necessary to use the frax as these pt already qualify for tx -when to use: BMD score is osteopenia T score of >-1.0 and used as an aid in decision making regarding tx initiation, for the concerned pt who does not meet criteria for DXA scan - when not to use: osteoporosis, already tx, younger than 40, have had prior hip or vertebral fx, does not incorporate spine BMD into the model or a medical hx of falls so women affected by these may receive erroneous underestimation of fx risk score

eval for amenorrhea

- hx, pelvic exam, pelvic US, chromosomal analysis

female orgasmic disorder tx

- increasing knowledge and options for the pt and partner - partner education about foreplay, clitoral stimulation, and change focus from just intercourse to mutual pleasuring - referral for more intense sex therapy and psychological therapy may be necessary

Asthma in pregnancy

- increasing prevalence, prevalence and severity are greater in women, women with severe asthma are at higher risk of complications, pt are at little to no increased risk if asthma is effectively tx and controlled -**ultimate goal of asthma therapy in pregnancy is maintaining adequate oxygenation of the fetus by preventing hypoxic episodes in the mother -dx: same as if not pregnant, confirmed by demonstrating **airway obstruction on spirometry that is at least partially reversible

ultrasounds

- initially to establish or confirm EDD - at 18-20 wks, targeted anatomical survey - at about 28-32 wks growth scan: **optional and elective

identifying risk factors

- medical: HTN, DM, infections, prev pre term birth, recurrent miscarriages, obesity, FHx of birth defects - lifestyle: IPV, tobacco, alcohol, drugs, supplements, herbals, food, travel, pet safety, workplace issues

ovarian and other female endocrine issues

- menopause and hormone replacement - amenorrhea - female infertility - PCOS - turner's syndrome

types of abnormal bleeding

- ovulatory bleeding: associated with menstrual cycle - anovulatory bleeding: caused by a disruption of the normal regulatory mechanisms that control the menstrual cycle, loss of normal ovulation

menopause pathophysiology

- reflection of complete or near complete ovarian follicular depletion, with resulting hypoestrogenemia and high FSH - decreasing estrogen levels: thermoregulatory set point lowered, serotonin levels decreased, thinning of vaginal epithelium, thinning of urethral epithelium, decreased blood flow to vagina/ vulva

mastitis

- tender, hard breast mass with an area of fluctuation, erythema, and heat - fever and chills common - staph aureus is most common - most often seen in lactating women

preeclampsia

-**HTN that occurs after 20 wks of gestation in a woman with previously normal BP, systolic >140 or diastolic >90, **proteinuria (defined as urinary excretion of >.3 g protein in a 24 hr urine, or **urinary protein: creatinine ratio of .3 mg/dL or higher), **edema facial and hand but this is no longer is a dx criterion - complications 5-7% of all pregnancies - the classic dx triad include: HTN, proteinuria, and edema - risk factors: age less than 20 yo or older than 35, nulliparity, multiple gestations, hydatidiform mole, DM, thyroid disease, chronic HTN, renal disease, collagen vascular disease, antiphospholipid syndrome, FHx of preeclampsia etiology - **maternal vascular endothelial injury plays a central role in the disorder -endothelial damage in preeclampsia results in decreased endothelial production of prostaglandin 12 (prostacyclin) a potent vasodilator and inhibitor of platelet aggregation -endothelial damage exposes subendothelial collagen and can trigger platelet aggregation, activation, and release of platelet derived thromboxane A2, a potent vasoconstrictor and stimulator of platelet aggregation - **decreased prostacyclin production by dysfunction endothelial cells and increased TXA2 release by activated platelets and trophoblast may be responsible for reversal of the normal ratio of prostacyclin and TXA2 observed in preeclampsia - **predominance of TXA2 may contribute to the vasoconstriction and HTN that are central features of the disorder - elevated intravascular pressure combined with damaged vascular endothelium results in movement of fluid from the intravascular to the extravascular spaces, leading to edema in the brain, retinae, lungs, liver, and subcutaneous tissues -HTN and glomerular endothelial damage lead to proteinuria - hemoconcentration is reflected in a rising hematocrit - consumption of platelets and activation of clotting cascade at the sites of endothelial damage may lead to thrombocytopenia and DIC - soluble fibrin monomers produced by the coagulation cascade may precipitate in the microvasculature, leading to microangiopathic hemolysis and elevation of the serum lactate dehydrogenase levels - cerebral edema, vasoconstriction, and capillary endothelial damage may lead to hyperreflexia, clonus, convulsions, or hemorrhage - hepatic edema and/or ischemia may lead to hepatocellular injury and elevation of serum transaminases and lactate dehydrogenase levels, the RUQ or epigastric pain observed in severe preeclampsia is thought to be caused by stretching Glisson's capsule by hepatic edema or hemorrhage - intravascular fluid loss across damaged capillary endothelium in the lungs may result in pulmonary edema - in the retinae, vasoconstriction and/or edema may lead to visual disturbances, retinal detachment, or blindness - but what causes the initial insult to the endothelium - decreased placental oxygenation triggers the placenta to release an unknown factor into the maternal circulation capable of damaging or altering the function of maternal endothelial cells and triggering the cascade of events described - NK cells attack trophoblasts, which should be protected by maternal ab (primiparaous pt would lack these ab) - invading trophoblastic cells in normal pregnancy undergo an antigenic shift to resemble vascular endothelial ag, masking them from recognition and rejection by decidual NK cells, invading trophoblasts in preeclamptic pregnancies may fail to make this antigenic shift, exposing them to recognition by NK cells and halting normal invasion - soluble fms-like tyrosine kinase 1 (sFlt-1) is increased in the placenta and serum of women with preeclampsia, this protein adheres to placental growth factor and vascular endothelial growth factor/ VEGF, preventing their interaction with endothelial receptors and causing endothelial dysfunction

the spectrum of the T score

-1.0: low bone mass** - 1.5: with risk factors, start tx -2.0: w/o risk factors, start tx -2.5: osteoporosis**

assessment during preconceptional care

-FHx -genetic hx -med, surgical, psychiatric, neuro hx - current meds - substance abuse - nutrition - environmental and occupational exposures - immunity and immunization status - risk factors for STDs - obstetrical hx - GYN hx - PE - socioeconomic, educational, and cultural context

luteal phase

-day 15-28 - corpus luteum produces progesterone and less potent estrogens - the functionalis layer increase in thickness - glands become tortuous with dilated lumens and stored glycogen

physical signs of menopause

-increased CV disease - increased bone loss and teeth - GU atrophy - skin atrophy - impaired cognitive function - increased risk of colon cancer

bacterial vaginosis tx

CDC regimen - metronidazole orally or gel - clindamycin cream

genetic screening tests

first trimester tests - beta hCG - PAPP-A - nuchal translucency fully integrated test - serum sample for PAPP-A b/n 9-13 wks, an US measurement of nuchal translucency and estimation of gestational age by crown rump length is performed b/n 10-13 wks - second trimester serum sample is drawn and the quadruple test markers are run - highest PPV, lowest false positive rate serum integrated test - same as the full integrated test, but w/o US measurement of nuchal translucency AFP quad test - AFP, uE3/ estradiol, beta hCG, inhibin A

tx of menopause

first try lifestyle changes - stop smoking - decrease alcohol: <3 drinks per day - regular exercise and weight management - adequate nutrition: Ca and vit D - stress reduction: meditation, yoga medical - hormone therapy - estrogen therapy along if uterus absent - combo estrogen and progesterone - progesterone - low dose oral contraceptive pills - alternative meds: phytoestrogens, black cohosh

primary dysmenorrhea tx**

general measures: • Reassurance and explanation Medical Measures • Nonsteroidal anti-inflammatory drugs* • Hormonal contraceptives (including hormone-releasing intrauterine devices and vaginal rings) • Progestins • Analgesics other measures • Transcutaneous nerve stimulation • Acupuncture • Psychotherapy • Hypnotherapy

medications during pregnancy**

prescription drug classification -A: adequate and well controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy and there is no evidence of risk in the later trimesters -B: Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women. - C: Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. -D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. -X: Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits. other drugs - teratogenicity of some illicit drugs are unknown, most illicit drugs like opioids will have a dependency issue w/in the fetus (withdrawal ssx after delivery)

vulvovaginal candidiasis vaginitis management

uncomplicated VVC - mild to moderate ssx: annoying - usually nonrecurrent or very infrequent - **75% of women have at least one episode in their lifetime - ssx responds to short course regimen complicated VVC - recurrent at least 4 or more times in one year - severe ssx with moderate to severe edema, excoriations and fissures, painful - overgrowth of a nonalbicans candidiasis - immune compromised host - pregnancy - 7-14 days of topical tx, or oral dose of fluconazole repeated in 3 days - maintenance regimen may be required **pt counseling/ education - reassure pt that VVC is not a STD and discuss risk reduction techniques such as avoiding douching, avoiding unnecessary abx use and how important it is to be completely compliant with the course of tx

vulvovaginal candidiasis vaginitis classification

uncomplicated VVC - sporadic or infrequent vulvovaginal candidiasis vaginitis - mild to moderate vulvovaginal candidiasis vaginitis - likely to be C albicans - non immunocompromised women complicated VVC - recurrent vulvovaginal candidiasis vaginitis - severe vulvovaginal candidiasis vaginitis - non albicans candidiasis - women with uncontrolled DM, debilitation, or immunosuppression or those who are pregnant

intimate partner violence/ IPV key points

*** - abused pts may deny the abuse for multiple reasons - pts for whom IPV is suspected but not acknowledged should be asked again at subsequent visits - before questioning a pt about abuse, it can be helpful to normalize the inquiry and frame the questioning as a routine part of everyday practice: violence can be a problem in many pt's lives, now ask every pt about trauma or abuse they may have experienced in a relationship, many pts seen are coping with an abusive relationship so start asking about IPV routinely - such statements may then be followed with specific questions

obstetric hx

*** - hx of any pregnancies - hx of miscarriages, terminations, or ectopic pregnancies - hx of assisted reproduction - for each pregnancy carried --date of delivery --gestational age at delivery -- mode of delivery: SVD/CS/ forceps, with indications for operative delivery --maternal complications, such as HTN or DM -- fetal complications, such as growth restriction, anomalies, stillbirth --delivery or operative complications --neonatal problems --current health of children

intimate partner violence/ IPV screening

*** - many advocate screening for IPV in health care settings, along with improved doc education - no gold standard available - systemic review found the following tools to have high sensitivity and specificity -- HITS: hurt, insult, threaten, scream -- STaT: slapped, threatened, and throw -- HARK: humiliation, afraid, rape, kick -- CTQ-SF: modified childhood trauma questionnaire short form -- WAST: woman abuse screen tool screening recommendations - present with suspicious ssx - pregnant women: recommended part of prenatal care, ACOG advises that all women be screened at periodic intervals, including during obstetric care, offer ongoing support and review available prevention and referral options - all pts on initial visits to primary care docs, OB/GYN, to the emergency department and on hospital admission

shorthand for obstetric hx

**** gravida: number of pregnancies para: outcomes of pregnancies - F: full term births - P: premature births, 20-37 wks - A: abortion, number of failed or terminated pregnancies at <20 wks - L: living children - multiple births count as one birth, but each living child is counted separately -ex G4P2103 G4: 4 total pregnancies P: TPAL (term, preterm, abortus, living).... 2 to term, 1 preterm, 0 abortus, 3 living 35 yo female pregnant 5 times, 2 vaginal deliveries and living, 2 abortions, 1 ectopic pregnancy G5P2032 21 yof currently pregnant with 7th child, 2 term deliveries with 1 living, 1 preterm delivery of twins with both living, 1 molar pregnancy, 1 ectopic pregnancy, 1 miscarriage G7P2133

menstrual hx- premenstrual syndrome/ PMS

**- emotional and behavioral ssx such as depression, angry outbursts, irritability, anxiety, confusion, crying spell, sleep disturbance, poor concentration, social withdrawal **- ask about ssx such as bloating and weight gain, swelling of the hands and feet, and generalized aches and pains **- criteria for dx are: ssx in the 5 days prior to menses for at least 3 consecutive cycles, cessation of ssx w/in 4 days after onset of menses, interference with daily activities

abnormal uterine bleeding

**-encompasses several patterns: polymenorrhea or fewer than 21 day interval b/n menses, oligomenorrhea or infrequent bleeding, menorrhagia or excessive flow, metorrhagia or intermenstrual bleeding, postcoital bleeding **- causes vary by age group and include pregnancy, cervical or vaginal bleeding, or cancer, cervical or endometrial polyps or hyperplasia, fibroids, bleeding disorders, and hormonal contraception or replacement therapy **- postcoital bleeding suggests cervical polyps, trauma or cancer, or in an older women, atrophic vaginitis

osteoporosis fracture prevention best option

**bisphosphonates -*** bIsPHosphonate (HIP)/ bISPhosphoNatE (SPINE) - reduce vertebral fx by 35-65 %: risedronate reduces nonvertebral fx,, alendronate and zoledronate reduce hip fx - inhibit osteoclastic activity - not recommended w/ renal or GI problems - must take on empty stomach, increases absorption

preconception counseling- over screening

**genetic - spinal muscular atrophy/ SMA - fragile X - cystic fibrosis - hemoglobinopathies: sickle cell anemia, alpha thalassemia, beta thalassemia - jewish descent carrier screening

menstrual hx- menopause

**postmenopausal women - in addition to other hx points: age of last menses, hx of hormone therapy, hx of postmenopausal bleeding, ask about vasomotor ssx (hot flashes, flushing, sweating, sleep disturbances), may be vaginal dryness and dyspareunia, or painful intercourse, hair loss, and mild hirsutism - **other questions you can ask: how do you feel about not having your periods anymore, has it affected your life in any way

managing GDM pt

- ***1st step is adequate counseling: pt have to understand the risks to them and the baby, diabetic counseling, nutrition counseling - pt may need to be admitted to hospital for this counseling and observation of their BG levels, esp if overt DM (class B or higher) management of overt DM - admit to hospital for tightening of glucose - **labs: HbA1C, CMP, UA, TSH, 24 hr protein and creatinine clearance - EKG - ophthalmology consult - **fetal surveillance: targeted fetal US at 18-20 wks and every 4 wks for fetal growth, fetal cardiac echo at 22 wks, NST (non stress test)/ BPP (biophysical profile... breathing mimicking, NST, movement, amniotic fluid volume) every wk beginning at 28 wks management of A1 or A1 GDM - +/- admit to hospital for BG tightening - **labs: HbA1C, UA - **fetal surveillance: targeted fetal US at 18-20 wks and every 4 wks for growth, NST/BPP every wk beginning at 32 wks, may delivery at 39-40 wks if poorly controlled at 37 wks or after nutritional goals - consult registered dietician - if BMI> 30, a 30% reduction in calories - **caloric restriction does bring concern of starvation ketosis -> ketones in 2nd and 3rd trimester may cause delay in psychomotor development and intelligence - 2000-2200 kcal/day - 45-60 g carbs per meal - average weight gain: 25-40 lbs **monitor glucose levels - target levels --fasting: 90 -- 2hr post prandial: 120

methyldopa for pregnancy HTN management

- **1st line antiHTN med for pregnancy - centrally acting alpha adrenergic agonist that appears to inhibit vasoconstricting impulses from the medullary vasoregulatory center - 500mg- 2g admin in 2-4 divided doses - peak plasma levels occur in 2-3 hr, and max effect occurs 4-6 hrs after oral dose - excreted primarily by kidney - sedation and postural hypotension are most common side effects - hemolytic anemia may occur in these pts and is an indication to stop the meds - fever, liver function abnormalities, granulocytopenia, and thrombocytopenia are rare side effects

gonorrhea

- **Caused by neisseria gonorrhoeae gram negative cocci - second most prevalent bacterial STD in US - **major cause of urethritis in men, cervicitis in women which may progress to PID leading to infertility, ectopic pregnancy, chronic pelvic pain - **increasing resistance to abx -attaches to columnar epithelial cells by pili and replicates in cells, produces inflammation and pus -**risk factors: younger age, multiple partners, unprotected sex, lower socioeconomic status - complications: men rare; **women infertility, PID, and increased risk for ectopic - **screening: sexually active women under 25, hx of STD, multiple partners, MSM - ssx: asymptomatic men but more in women - **classic: burning, dysuria, copious discharge that is more pus than chlamydia - **pelvic exam: discharge/ bleeding, cervical motion tenderness, cervical friability, ulcers - **bimanual exam: no to mild uterine tenderness - RUQ pain: Fitz- Hugh- curtis syndrome from PID - **PID: 10-40% with gonorrhea will go on to develop PID

***HELLP and management

- **Hemolysis, Elevated Liver enzymes, Low Platelets - complicates 10% of cases of severe preeclampsia and up to 50% of eclampsia cases - RUQ pain, N/V, and malaise are common - the hallmark of the disorder is microangiopathic hemolysis leading to elevation of serum lactate dehydrogenase level and fragmented RBC on peripheral smear - transaminase levels are elevated, thrombocytopenia is present, and DIC may be evident ***management - similar to that of preeclampsia with severe features - dexamethasone may hasten the improvement of HELLP syndrome following delivery, admin IV in 4 doses of 10mg, 10 mg, 5 mg, and 5 mg at 12 hr intervals or in doses of 10mg IV at 12 hr intervals until improvement -if elevated transaminase levels or thrombocytopenia persist beyond the fourth postpartum day, alternate explanations should be considered including: thrombotic thrombocytopenic purpura/TTP, hemolytic uremic syndrome/HUS, acute fatty liver of pregnancy, viral or drug induced hepatitis, SLE

menstrual hx- amenorrhea

- **absence of period --**primary amenorrhea: absence of menarche by age 15/16 in the presence of normal growth and secondary sexual characteristics --**secondary amenorrhea: cessation of menses for more than 3 months in girls or women who previously had regular menstrual cycles or 6 months in girls or women who had irregular menses - **causes vary by age group: somes causes include pregnancy, anatomic abnormalities, low body weight, eating disorders, disorders of the hypothalamus, pituitary, ovaries, uterus, or vagina

menstrual hx

- **age at menarche: variable; depends on genetic endowment, socioeconomic status, and nutrition; in US usually b/n ages 9-16 yo - **date of last menstrual period/ LMP: first day of bleeding or spotting, if possible the one before that as well - **how often does the pt have periods: measured by the interval b/n the first days of successive periods, the interval b/n periods ranges roughly from 24-32 days - **how regular or irregular are they: cycle patterns over past year - **how long do they last: flow usually lasts from 3-7 days - **how heavy is the flow: can be assessed roughly by the number of pads or tampons used daily, because women vary in their practices for sanitary measures ask abouts methods, also does she use more than one at a time - **what color is it: unlike the normal dark red menstrual discharge, excessive flow tends to be bright red and may include clots (not true fibrin clots) - **does she have any bleeding b/n periods - **any bleeding after intercourse

chlamydia trachomatis clinical presentation

- **classic: dysuria, burning, mucopurulent discharge, easy endocervical bleeding - **PID: may extend into upper reproductive tract, abd/pelvic pain most common ssx, present w/in 2 wks of infection of lower tract -**pelvic exam: vaginal discharge and/or bleeding, cervical motion tenderness (CMT: positive chandelier sign), swollen inflamed friable cervix, ulcerations - **bimanual exam: none to severe uterine/adnexal tenderness, +/- adnexal fullness/ tenderness - **RUQ tenderness/ pain: Fitz-Hugh-Curtis syndrome - associated findings: conjunctivitis, pharyngitis, LGV, proctitis

bacterial vaginosis

- **commonly associated with gardnerella vaginalis - characterized by a **shift in normal vaginal flora away from lactobacillus toward a more pathologic diversity - this change causes a **rise in vaginal pH which promotes bacterial overgrowth and the production of amines - gardnerella vaginalis may form a biofilm that adheres to the vaginal epithelium, allowing other bacterial to infect the cells as well - **most common cause of vaginitis in US - up to 50% in reproductive age black women -**infection could lead to premature rupture of membranes, premature delivery, low birth weight, acquisition of HIV, PID and post op infections after GYN surgery - **organisms do no persist in the male urethra - **thought to be sexually transmitted infection, however it has not yet been classified as such

vaginal environment

- **dynamic ecosystem - **contains 10^9 bacterial colony forming units - normal discharge is **clear to white, odorless, and of high viscosity - lactobacilli are the dominant normal flora but other bacilli that potentially are pathogenic are present - normal pH is 3.8-4.2 and is maintained by lactic acid and acts to inhibit bacterial overgrowth - some lactobacilli also produce H2O2 which is a strong microbicide

chlamydia trachomatis

- **highest incidence in young women - **leading cause worldwide for infertility - infection of lower genital track including vaginal infections, cervicitis, and urethritis - **risk factors: younger age, multiple partners, lack of condom use - pathology: **obligate intracellular gram negative - **screening: all sexually active women under 25, those with hx of STD, hx of multiple partners

tuba-ovarian abscess/ TOA management

- **immediate surgery: rupture/ leak, signs of shock (hypotension, tachycardia, tachypnea, acidosis, acute peritoneal signs), any worsening ssx or failure to respond to abx - **start abx as soon as possible preop - if not surgical case, **admit for IV abx and monitoring for deterioration

tuba-ovarian abscess/ TOA

- **inflammatory mass of fallopian tube and/or ovary - **serious and life threatening condition - **seen in over 1/3rd of PID cases, most b/n 15-40 YO, hx of multiple sex partners, prior hx of STD, hx of HIV - may arise from PID, spread form local infection, adnexal surgery and on rare occasions from hematologic speed - **results in tubal blockage due to progressive edema of involved structures, ischemia and necrosis; prior infections may alter tissue promoting formation of TOA - **abscess is polymicrobial with E. coli, aerobic strep, B fragilis, and other anaerobic... TOA associated with actinomyces israelii infection

Asthma in pregnancy complications

- **maternal complications: hyperemesis gravidarum, pneumonia *asthmatics account for >60% of cases during pregnancy), preeclampsia, vaginal bleeding, more complicated labors, more C sections -**fetal complications: IUGR, preterm birth, low birth weight, neonatal hypoxia, increased overall perinatal mortality

patterns of abnormal uterine bleeding

- **menorrhagia/ hypermenorrhagia: heavy or prolonged menstrual flow, submucosal myomas, adenomyosis, IUDs, malignant tumors - **hypomenorrhea/ cryptomenorrhea: unusually light menstrual flow, sometimes only spotting, obstruction/ cervical stenosis, OCPs - **metorrhagia/ intermenstrual bleeding: bleeding that occurs at any time b/n periods, endometrial polyps or carcinoma - **polymenorrhea: periods that occur too frequently, anovulation -** menometorrhagia: bleeding that occurs at irregular intervals - **oligomenorrhea: menstrual cycles that occur more than 35 days apart, systemic (excessive weight loss), endocrine (pituitary hypothalamic causes, menopause), estrogen secreting tumors - **amenorrhea: no period for more than 6 months - **contact bleeding/ postcoital bleeding: must be considered a sign of cervical cancer until proven otherwise, cervical eversion, polyps, infection, atrophic vaginitis the amount and duration may vary, possible malignant tumor, complication of pregnancy

trichomonas vaginalis tx

- **metronidazole - no follow up unless ssx persist - **assure that sex partners have been tx before further relations - can be used in pregnant pt: does cross placenta but classified as category B tx failure - retreat with metronidazole - assure tx of sex partners - if repeat tx fails contact CDC for metronidazole susceptibility testing **pt counseling - explain nature of disease, can be symptomatic or asymptomatic - explain that douching may worsen discharge - if untx can produce adverse outcomes for pregnancy while infected - STD and that fomite transmission is rare - if untx or partially tx, can last for months to years - explain increase risk of HIV acquisition - to reduce risk, assess potential behavior changes, discuss risk reduction plans with pt such as abstinence, monogamy, condom use, and limiting number of sex partner - explain that when used properly and consistently, latex condoms can reduce the risk of transmission

trichomonas vaginalis dx

- **motile trichomonads on saline wet mount - **pH >4.5 - **fishy odor: positive amine test - culture is gold standard - pap smear has limited sensitivity and low specificity - DNA probe useful - male dx: culture - first void urine concentrated - urethral swab

chlamydia trachomatis dx

- **nucleic acid amplification/ NAAT: now gold standard - culture is not helpful clinically - **rapid tests: for endocervical, vaginal swabs and urine, cheaper, results in minutes but still not gold standard

bacterial vaginosis clinical presentation

- **over half of infected women are asymptomatic - most common ssx complaints are **vaginal discharge and or fishy vaginal odor, noted most commonly after intercourse and after menses - **discharge is thin, white to off white and homogeneous - alone does not cause dysuria, dyspareunia, pruritus, burning or vaginal erythema or edema... if present these ssx would suggest a **mixed vaginitis - **consequences of BV include preterm delivery, post delivery/ post op complications, increased risk for HIV, HSV2, gonorrhea, chlamydia, and trichomonas infection

hormone released in pregnancy that promotes more articulation in the joints, esp the pelvis

- **relaxin: secreted by corpus luteum, relaxes ligaments esp SI joint and pubic symphysis - elevation in estradiol, progesterone, and HCG leads to increase fluid volume

condyloma acuminatum/ genital warts

- **soft, fleshy cauliflower like lesions around vulva, glans, urethral orifice, anus, perineum - not associated with adenopathy or systemic issues - dx: **clinical, biopsy rarely needed - tx: topical podophyllin, surgical excision

obstetrics intestine changes

- **transit times are decreased in the 2nd and 3rd trimesters, whereas 1st trimester and postpartum transit times are similar. transit times return to normal w/in 2-4 days postpartum - the reduced GI motility during pregnancy has been thought to be caused by increased circulating concentration of progresterone - the slow transit time of food through the GI tract potentially enhances water absorption, predisposing to **constipation

bacterial vaginosis screening concerns

- **tx of male partners not recommended - female partners of women should be examined - screen and tx women prior to surgical abortion or hysterectomy - in absence of ssx, screening low risk pregnant pt is not recommended recurrence - may be due to bacterial persistence or failure of lactobacillus to recolonize - **yogurt therapy or oral lactobacillus are not supported - vaginal suppositories containing human lactobacillus strains are being studied

when to rescreen with a repeat DXA

- **untx women 15 yrs with normal BMD T >-1.5: repeat FRAX yearly to asses risk - **tx women depends on T score: after tx initiation, one DXA per yr or 2 yrs can be used to assess tx, if BMD is improved or stable then does not need to be repeated in the absence of new risk factors

menstrual hx- dysmenorrhea

- **up to 50% of women report pain with menses - **ask if the pt has any discomfort or pain before or during her periods: what is it like, how long does it last, does it interfere with usual activities, are there other associated ssx - **may be primary (w/o organic cause) or secondary (with an organic cause) --**primary: results from increased prostaglandin production during the luteal phase of the menstrual cycle --**secondary: some causes can include endometriosis, adenomyosis, PID, and endometrial polyps, low body weight from any cause (malnutrition and anorexia nervosa), stress, chronic illness, hypothalamic-pituitary-ovarian dysfunction

pelvic inflammatory disease

- **upper genital track infection/ inflammation - may present as endometritis, salpingitis, oophoritis, tuba-ovarian abscess, and/ or pelvic peritonitis - **acute presentation over several days, presentation vary from asymptomatic to shock for infection or hemorrhage - **gonorrhea and chlamydia are leading causes, but other vaginal infections may also be causative, polymicrobial etiology is common - **all women with PID should be tested for GC and C trachoma's along with HIV - PID is leading cause of infertility, thus a low threshold for dx is warranted - PID in the second and third trimesters is **rare as mucous plug prevents ascension into the uterus

syphilis

- **wide range of presentations/ ssx - ** caused by treponema palladium - **new resurgence - bacteria coiled and moves in corkscrew motion, it cannot be cultured - infects/ penetrate mucosal membranes leading to classic chancre lesion, then infects lymph node and spreads to all parts of the body, crosses placenta easily - **has 4 stages: primary, secondary, latent, and tertiary - **40% will progress to tertiary - transmission: 30% with first exposure, via orogenital route or needle stick, sexual transmission requires exposure to open lesions with organism, increased risk with MSM and with positive HIV status - ***dx with dark field microscopy or fluorescent ab techniques

vulvovaginal candidiasis vaginitis epidemiology/ microbiology

- **will affect almost all females during their lifetimes, second most common cause of vaginitis and is highest in women in their reproductive years - leading cause is overgrowth of **candidiasis albicans, a normal flora of the skin and vagina in many women. it is **NOT considered a sexually transmitted disease - becomes symptomatic the greater the overgrowth and penetration of the superficial epithelial cells - disruption of the normal vaginal environment or host immunity issues can predispose - **risk factors: DM, abx use, increased estrogen levels from OCs, pregnancy, and estrogen therapy, immunosuppression, use of contraception devices

subsequent OB visits

- 0-28 wks gestation: visit every 4 wks - 28-36 wks: visit every 2 wks - >36 wk: visit every wk - at each visit: maternal weight, BP, urine dipstick, fundal height, fetal heart tones, edema, pain scale, fetal size by leopold's maneuver's, and fetal position - at 26-28wks: check Hb/HCT, sono for fetal weight, ab screen if pt is Rh negative, 1 hr glucose tolerance test - 34-35 wks: maternal group B strep screen, eval for cervix change if pt is contracting

paget's carcinoma

- 1% of all breast cancers - majority associated with underlying invasive or non invasive cancer - red, scaling, crusty patch on the nipple or areola w/ pruritus - u/l or b/l

GDM threshold screening value

- 140: lower sensitivity but high specificity, lower likelihood of false positive - 130: higher sensitivity but lower specificity, higher likelihood of a false positive

human sexual response

- 1966 Masters and Johnson first described the physiology of human sexual response cycle - describe 4 phases of the sexual response cycle: excitement, plateau, orgasm, and resolution - Helen Singer Kaplan later described a more subjective, psychologically oriented response model with 3 phases: desire, excitement, and orgasm - women may have a brief plateau followed by orgasm or a long plateau with no orgasm, and may have multiple orgasms before resolution - men with premature ejaculation have a brief plateau phase; men after ejaculation enter a refractory period lasting minutes to hours which they are unable to ejaculate

why is there concern with osteoporosis

- 24% mortality following hip fracture: 20% require nursing home care, 85% require aid for ambulation, 50% will never walk independently again - 5.1% of men >65 you with osteoporosis of the femur neck or lumbar spine - 24.5% of women >65 yo with osteoporosis of femur neck for lumbar spine

turner syndrome

- 45X or 46XX - streak gonad or female immature ovary - infancy: lymphedema, web neck, shield chest, low set hairline, cardiac defects, and coarctation of the aorta, urinary tract malformations, horseshoe kidney - childhood: short stature, cubitus valgus, short neck, short fourth metacarpals, hypoplastic nails, micrognathia, scoliosis, otitis media, sensorineural hearing loss, ptosis and amblyopia, multiple nevi and keloid formation, autoimmune thyroid disease, visuospatial learning difficulties - adulthood: pubertal failure and primary amenorrhea, HTN, obesity, dyslipidemia, impaired glucose tolerance and insulin resistance, autoimmune thyroid disease, CV disease, aortic root dilation, osteoporosis, inflammatory bowel disease, chronic hepatic dysfunction, increased risk of colon cancer, hearing loss

pregnancy HTN management

- ACE inhibitors are contraindicated: associated with fetal hypocalvaria, renal defects, anuria, abnormal limb development, fetal and neonatal death - ARBs are contraindicated used during pregnancy - methyldopa -labetalol - hydralazine - procardia - others: atenolol, metoprolol, prazosin, minoxidil, thiazide diuretics, clonidine

eval of the female partner for infertility- PE

- BMI should be calculated and fat distribution, extremes are a/w reduced fertility - signs of incomplete development of secondary sexual characteristics - abnormalities of the thyroid gland, galactorrhea, or ssx of androgen excess suggest the presence of a endocrinopathy - tenderness or masses in adnexae or posterior cul-de-sac (pouch of douglas) are a/w chronic PID or endometriosis - vaginal and cervical structural abnormalities or discharge suggest the presence of a mullerian anomaly, infection, or cervical factor - uterine enlargement, irregularity, or lack of mobility are ssx of a uterine anomaly, leiomyoma, endometriosis, or pelvic adhesive disease

C section with GDM

- C sections rates ARE higher in GSM: doc more likely to perform C section due to risks of shoulder dystocia - problems: US are highly unpredictable when measuring term infants, especially if they are LGA - analytical model was developed to estimate the potential effectiveness and costs of a policy of ELECTIVE C section for macrosomia -- 489 c section would need to be performed to prevent 1 shoulder dystocia at 4,000 g EFW -- 443 C section would need to be performed to prevent 1 shoulder dystocia at 4,500 g EFW threshold - when EFW > 4,500 g in a GDM pt, elective C section should be strongly considered (threshold is 5,000 g if not GDM)

initial OB visit labs

- CBC - blood type and screen for Rh - serological testing: VDRL or RPR - rubella immune status: IgG - hep B surface ag - HIV - urinalysis and urine culture - pap smear - gonorrhea and chlamydia screen - TB skin test - sickle cell screening-offer - cystic fibrosis screening- offer - if prior hx of gestational DM: a 1 hr glucose challenge test may be performed, 50g glucose ingestion followed by serum glucose screening one hr later, >140mg/mL is abnromal - 1st trimester genetic testing such as PAPP-A can be offered at 11-12 wks, this is part of an integrated screening with later testing for hCG, inhibit, unconjugated estriol, and AFP (alpha fetoprotein), this is done b/n 15-19 wks, this is called a quad screen

procardia for pregnancy HTN management

- CCB - inhibits Ca ion influx into vascular smooth mm and myocardium - 30mg, 60mg, 90mg

eval of abnormal bleeding in reproductive age women

- H&P, pregnancy test - menorrhagia: CBC, coagulation profile, LFT, BUN/creatinine, pelvic US to exclude fibroids, endometrial biopsy in >35 yo - intermenstrual bleeding: pap smear, cervical cultures - anovulatory bleeding: CBC, TSH, prolactin, fasting glucose, insulin, screen for eating disorder, stress, and female athlete triad

preconception counseling- lab assessment

- HIV screening and counseling is recommended for all women planning pregnancy due to tx of maternal HIV can reduce risk of congenital infection - screen for gonorrhea, chlamydia, syphilis, hepatitis, and other STIs - document immunity or lack of for rubella and varicella: can have serious adverse effects on the fetus and can be prevented by prepregnancy immunization (immunization with live vaccine cannot be performed in pregnancy) - glycated hemoglobin/ A1C in women with pregestational DM: good glucose control in early pregnancy reduces risk of miscarriage and congenital anomalies - primary screening for T2DM: hx of dyslipidemia and HTN should undergo screening for occult T2DM as part of overall CV risk assessment, screen those with risk factors for DM (>40yo, overweight, hx of A1C in prediabetes range, hx of gestational DM), consists of fasting plasma glucose/A1C/ or both - lead level: if high risk of lead exposure or increased lead level - serum phenylalanine level: if maternal phenylketonuria is known or suspected - tuberculin skin test in high risk population - toxoplasmosis screening is controversial: if negative then should counsel to avoid cat litter changing, eating undercooked meat, wear gloves when gardening, and frequently wash hands, food, and food prep areas - CMV infection screening is controversial: the highest risk of seroconversion is in mothers who have recently placed a toddler in day care

preconception counseling- key components to medical assessment

- ID use of meds (OTC and prescription drugs) that are teratogenic and may be stopped, should be stopped, or can be changed to a safer one - elicit exposure to dietary supplements as pt may not perceive them as meds that can be harmful to fetus - human teratogenic risk is undetermined in 98% of drugs and only approx 30 drugs are considered to be proven safe in pregnancy: most of these are vitamins, minerals, electrolytes, and hormone replacements at physiological doses -*** resources for info on potential teratogens: National library of medicine, reproductive toxicology center, teratogen info system, pregnancy exposure registries

hypothyroidism in pregnancy tx/ management

- L thyroxine is tx of choice: taken early morning on empty stomach, but if have n/v can take later in the day -T4 only is recommended - thyroxine requirements increase during pregnancy - if TSH is elevated, increase meds - changes made at less than 4 wk intervals may lead to overtx - up to 85% of women receiving thyroxine replacement before pregnancy will require higher doses while they are pregnant - check TSH early in pregnancy and every trimester - free T4 should be kept in the upper third of normal

***hyperemesis gravidarum

- N/V affects more than 70% of pregnancies - hyperemesis gravidarum affects 2% of all pregnancies - unrelenting , excessive pregnancy related N/V that prevents adequate intake of food and fluids - weight loss and inadequate nutrition may require hospitalization

advice during pregnancy alleviating unpleasant ssx

- N/V complicate up to 70% of pregnancies - heartburn affects about 2/3 of women at some stage of pregnancy - constipation/ hemorrhoids - leg cramps are experienced by almost half of all pregnant women, particularly at night and in the later months of pregnancy - backaches

define osteoporosis

- a skeletal disease characterized by compromised bone strength predisposing a person to an increased risk of fractures - osteopenia: reduced bone mass of lesser severity than osteoporosis - fragility fracture: any fall from a standing height or less that results in a fracture - **T score: the value compared to that of control subjects who are at their peak bmd - **Z score: reflects a value compared to that of pts matched for age and sex - **DXA scan: hip and spine, reported as standard deviation from mean and applied to **T score

perimenopausal women abnormal bleeding

- abnormal bleeding for 5-10 yrs before menopause is very common - most common cause is anovulation due to decreasing number of ovarian follicles - structural lesions: most often uterine fibroids or polyps - bleeding disorders - risk of endometrial cancer increased in women who are nulliparous, DM, or obese

bisphosphonates contraindications

- abnormalities of esophagus - inability to stand or sit upright for at least 30 min - hypersensitivity to any component of this product - hypocalcemia - pt at increased risk of aspiration should not receive fosamax oral solution

breast cancer in men statistics

- about 1% of breast cancer - more than 2000 men are dx annually in US - average age is 70 - prognosis worse than women - hormonal influences - BRCA2

confirming pregnancy and determining viability

- about 30-40% of all pregnant women will have some bleeding during early pregnancy (implantation bleeding) which may be mistaken for a period: **a pregnancy test should be performed in all women of reproductive age who present with abnormal vaginal bleeding - detect hCG in serum or urine - hCG is the **first detectable in serum 6-8 days after ovulation - **a titer of less than 5 IU/L is considered negative, a level above 25 IU/L is a positive - **values b/n 6-24 IU/L are considered equivocal and should be repeated in 2 days - a concentration of 100IU/L is reached about the date of expected menses - most qualitative urine tests can detect hCG above 25 IU/L - it is important to differentiate a normal pregnancy from a nonviable or ectopic gestions: **in the first 30 days of normal gestation the level of hCG doubles every 2/2 days; **in pt whose pregnancies are destined to abort the level of hCG rises more slowly, plateaus, or declines - transvaginal US: improved accuracy of predicting viability in early pregnancies - **gestational sac should be seen at 5 wks gestation or a mean hCG level of about 1500 IU/L - **fetal pole should be seen at 6 wks or a mean hCG level of about 5200 IU/L - **fetal cardiac motion should be seen b/n 6 and 7 wks or a mean hCG of about 17500 IU/L

bacterial vaginosis risk factors **

- absence of or significant decrease in lactobacilli - recent abx use - presence of other STDS seem to promote development of BV - reports of higher rates in minority populations but precise reason for this is unclear - two or more sex partners in previous six months/ new sex partners - failure to use condoms - douching - cigarette smoking and high fat diets have been implicated

LARCS: long acting reversible contraceptives

- according to the WHO evidence based medical eligibility criteria for contraceptive use: LARC methods have few contraindications, almost all women are eligible for implants and uterine devices - because of these advantages and the potential to reduce unintended pregnancy rates: LARC methods should be offered as first line and encouraged as options, need to address barriers that prevent LARC use (lack of health care provider knowledge or skills, low pt awareness, high upfront cost)

estimating gestational age and date of confinement

- accurate dating is crucial for managing the pregnancy, especially with regard to timing interventions and monitoring fetal growth - clinical assessment to determine gestational age is usually appropriate for women with regular menstrual cycles and a known LMP that was confirmed by an early exam - US may also be used to estimate gestational age: measurement of fetal crown rump length b/n 6-11 wks gestation can define gestational age to w/in 7 days - estimated date of confinement (EDC) or due date may be determined by adding 9 months and 7 days to the first day of last menstrual period

combined oral contraceptives unacceptable health risks

- age >35 and smoking >15 cigarettes per day - multiple risk factors for arterial CV disease: such as older age, smoking, DM, HTN - venous thrmboembolism - known thrombogenic mutations - known ischemic heart disease - hx of stroke - complicated valvular heart disease: pulmonary HTN, risk for A fib, hx of subacute bacterial endocarditis - SLE - migraine with aura at any age, any migraines in >35 yo - breast cancer - cirrhosis

erectile dysfunction

- aka impotence - defined as inability to achieve and maintain an erect penis capable of intercourse - etiology can be multifaceted from physiologic, psychological, effects of substances - sympathetic and parasympathetic nerves regulate the blood flow into the corpus cavernosum - the intact functioning of 4 body systems (vascular, neurologic, endocrine, and psychological) is necessary to experience a penile erection - erectile dysfunction can occur at any age, but prevalence increases with age

DXA screening for osteoporosis

- all women >65 - postmenopausal women <65 if have risk factor - postmenopausal women with fracture to confirm dx - premenopausal with medical condition or drug exposure that places them at high risk -absence of data supporting routine BMD testing in men: not performing routine testing in men, do get a measurement of BMD in men with clinical manifestations of low bone mass ( Xray osteopenia, hx of low trauma fracture), loss of more than 1.5 in in height, as well as those with risk factors for fractures

sexuality issues at specific times of life

- almost half of high school students report having experience sexual intercourse, with 15% reporting experience with four or more partners - 84% of high school students report being taught about HIV/AIDS in school; only 2/3 of sexually active male youth report condom use with their last sexual intercourse - 12% of female adolescents and 5% of males report being forced to have sexual intercourse they did not want; almost 10% of adolescents report being hit, slapped, or physically hurt on purpose by a partner - gender dysphoria can become apparent in young children or adolescents - 84% of LGBTQ youth report verbal harassment, 30% report physical abuse, and more than 1/4 of them drop out of school due to harassment - the likelihood of being sexually active correlates with good health status; older women may be less likely to have a spouse or intimate partner due to their greater longevity - testosterone levels are lower in men with chronic illnesses than in healthy men - before testosterone replacement, men should have their prostates evaluated with a PSA and digital rectal exam; PSA should be drawn annually; hematocrits should be monitored in men on testosterone

labetalol for pregnancy HTN management

- alpha 1 adrenergic blocker and a nonselective beta adrenergic blocker - safe during pregnancy - it appears to lack teratogenicity and crosses placenta in small amounts - no advantage over methyldopa - higher incidence of small for gestational age/ SGA newborns in pt tx with labetalol - usual starting dose is 100mg BID, and the dose can be increased weekly to a max of 2400 mg daily

eval for secondary amenorrhea

- always rule out pregnancy - structural changes can cause secondary amenorrhea: adhesions after surgery, infections, endometriosis - hypergonadotropic hypogonadism (premature ovarian failure), thyroid disease, menopause, extreme exercise, anorexia nervosa, bulimia, hyperprolactinemia are possible etiologies - H&P - lab: HCG, TSH, prolactin - if normal labs do progesterone challenge - management is based on tx the underlying cause, restoration of ovulation cycle, and tx infertility

***acute pelvic pain caveat

- always... always in pt with acute pelvic pain consider the following conditions - acute appendicitis - tubo-ovarian abscess/TOA - ectopic pregnancy

presumptive manifestations of pregnancy

- amenorrhea: absence of menstruation - N/V: most common in 1st trimester, **hyperemesis gravidarum is protracted vomiting with associated dehydration and ketonuria and may require hospitalization - breasts: mastodynia, enlargement of circumlacteal sebaceous glands of the areola (montgomery's tubercles); colostrum secretion may begin after 16 wks gestation - quickening: first perception of fetal movement usually 18-20 wks - urinary tract: bladder irritability, UTI - increased basal body temp - skin: chloasma (mask of pregnancy), linea nigra, stretch marks, spider telangiectases

adolescents abnormal vaginal bleeding

- anovulation: normal for cycles to be anovulatory for up to 18 months after menarche - menorrhagia: common and usually secondary to anovulation, may be sign of a bleeding disorder, up to 24% may have undx bleeding disorders - amenorrhea: may be seen with pregnancy, chromosomal abnormalities, hypothalamic hypogonadism, congenital absence and structural abnormalities of organs

obstetrics GI anatomic changes

- as the uterus grows, the stomach is pushed upward and the large and small bowels extend into more rostrolateral regions - the appendix is displaced superiorly in the R flank area

preconception counseling- PE

- assessment of heart, breasts, lungs, thyroid, abd, mouth, genital tract, BP, BMI - the exam is to detect the most common conditions that can affect maternal health and pregnancy outcome

medical/ obstetrical hx

- at or prior to the first prenatal visit, it is efficient for the pt to complete a questionnaire detailing her psychosocial, medical, obstetrical, and FHx: used to start an obstetrical record that will document her prenatal, intrapartum, and postpartum course; several paper and computerized obstetrical record forms are available for this purpose - major elements include: personal and demographic info, post obstetrical hx, personal and family hx, genetic screening, past surgical hx, menstrual and GYN hx, current pregnancy hx, travel to areas endemic for malaria, TB, and zika; psychosocial info

chlamydia trachomatis tx

- azithromycin or doxycycline - **repeat testing on pregnant testing, those still symptomatic and men who have sex with men - **expedited partner therapy/ EPT: may tx w/o seeing partner

intimate partner violence/ IPV mandatory reporting

- be familiar with state or country law regarding situations for which reporting is mandated - health providers and law enforcement officers, as well as teachers and child care providers, are mandated reporters in most states - domestic violence programs, either hospitalized based or in the community, can often provide assistance with reporting and/or guidance about whether reporting is indicated situations that commonly require reporting are -**abuse of disabled persons: harm to disabled pt must be reported to the disabled person protection commission - ** weapon use: in most states, injury resulting from assault with a firearm or knife causing grave bodily harm is reportable - **elder abuse: many states have mandatory reporting laws for elder abuse - ** abuse involving children: w/n the US, domestic violence involving a child, including children who are witnesses to domestic violence, must be reported if the following criteria are met... under the age of 18 and abuse or neglect of the child is suspected

reproductive cycle

- be viewed from the perspective of each of 4 physiologic components: hypothalamic (arcuate nucleus), pituitary (anterior), ovarian, endometrial - events occur in concert in a uniquely integrated fashion

intimate partner violence/ IPV

- behavior by an intimate partner or ex-partner that causes physical, sexual, or psychological harm, including physical aggression, sexual coercion, psychological abuse, and controlling behaviors - data on IPV underscore the magnitude of the problem - serious but preventable public health problem: until recently could be described as a silent epidemic - must be knowledgeable about and comfortable with the eval and care of pts who are subjected to IPV - team approach with medical, institutional, and community resources - the social and economic costs of intimate partner and sexual violence are enormous and have ripple effects throughout society - underdiagnosed too frequently since pts often conceal that they are in abusive relationships - clues pointing to abuse may be subtle or absent

transdermal contraceptive patch

- benefits, risks and contraindications are similar to those of OCs - women may choose: ease of admin and convenience, less private as it is visible - self admin weekly rather than daily, applied to butt, abd, upper arm, or upper torso - quicks start is reasonable - changed X1 a wk for 3 wks, followed by one wk that is patch free

nipple discharge intraductal papilloma

- benign conditions - single or multiple - usually u/l - discharge is serous or bloody - mass behind nipple may be present

medications affecting sexual function

- beta blockers - thiazide diuretics - sympatholytics - CCB - ACE inhibitors - antipsychotics - antidepressants - anxiolytics - 5 alpha reductase inhibitors - ketoconazole - spironolactone - H2 blocker - HIV meds - fibrates - statins - digoxin

transient hyperthyroidism of hyperemesis gravidarum

- biochemical hyperthyroidism is seen in most women with HG - differentiating b/n thyrotoxicosis and HG: HG has no goiter, no hx of thyroid disease, no other ssx of thyroid disease except tachycardia, no thyroid abnormalities - most likely mechanism is thyroid stimulation by HCG - tx: will usually resolve in 1st trimester, thyroid meds usually not indicated

breast cancer dx tests

- biopsy - US - mammography - ductography - cytology - MRI

long term consequences of estrogen deficiency due to menopause

- bone loss: begins during the menopausal transition, rate of loss highest in the year prior and for 2 yrs after - CV disease: risk increases, thought to be partly due to estrogen deficiency, possibly due to changes in lipid profiles - dementia: limited epidemiologic support - osteoarthritis: contribute to the developement - body composition: gain fat mass and lose lean mass - skin changes: collagen content of the skin and bone is reduced - balance: may be a central effect of estrogen deficiency

osteoporosis pathophysiology

- bone repairs itself by constant rebuilding: osteoBlasts Build, osteoClasts Consume - cortical bone: outer shell mass, 75% of bone - trabecular bone: spongy, interlacing network - bone mass peaks b/n 12-19 - most rapid bone loss in women-menopause: remodeling of bone continues throughout life but with estrogen def osteoclastic activity exceeds osteoblasts' ability to lay down bone, one yr before final menses for about 3 yrs

combined oral contraceptives side effects

- breakthrough bleeding: reassure, rule out pregnancy and pathology, confirm correct use, increase estrogen - nausea: reassure, take in evening, lower estrogen - weight gain: may see cyclic changes due to fluid retention, some women may have increase appetite, often can't blame on pill - breast tenderness: reassure, check pregnancy test, lower estrogen dose - H/A: if severe, frequent, worsening -> change method, if not can reassure, check BP - HTN: if high BP once then ok to continue OCs but recheck, if persistently high then consider method switch

breast self exam

- breast self awareness has replaces BSE as a tool in detection of cancer - american cancer society no longer recommends all women perform monthly BSE, it does support it as an option for those comfortable in performing it

preconception counseling

- broad term that refers to the process of ID social, behavioral, environmental, and biomedical risks to a woman's fertility and pregnancy outcome with the goal of reducing these risks through education, counseling, and appropriate intervention - preconception care, esp education, should begin at the time a woman reaches reproductive age, not only when she announces the desire to become pregnant - several barriers to providing preconception care, including time constraints due to competing priorities w/in the practice setting, lack of health insurance, or lack of adequate coverage for screening tests and counseling, and lack of resources for assisting in the delivery of info

tx principles for menopause

- by convention, unopposed estrogen therapy/ ET , combined estrogen progestin therapy/ EPT, and menopausal hormone therapy/ MHT - almost all women who seek medical therapy for menopausal ssx do so in late 40s or 50s - goal: relieve menopausal ssx - tx for hot flashes: require systemic estrogen which is the most effective - tx for vulvovaginal atrophy with low dose vaginal estrogen rather than systemic estrogen

other osteoporosis fracture prevention options

- calcitonin: inhibit osteoclast activity, only proven to reduce spine not hip fractures - Rpth/ recombinant human parathyroid hormone: activates bone formation, severe disease only, restricted to 2 yr total use - SERM/ selective estrogen R modulators: reduces the risk of vertebral fx, chosen if need breast cancer prophylaxis

combined oral contraceptives follow up

- can be addressed during routine periodic exams scheduled for other health maintenance issues: assess compliance/ satisfaction, BP check - counseling is important - women should be encouraged to return if they have any concerns about their method or want to discontinue or switch methods - continuation of the contraceptive method is enhanced if the pt receives a prescription, or even better, a supply for a full year of pills

diabetic pregnant pt define

- carb intolerance leading to hyperglycemia with onset or first recognition during pregnancy

**central/true precocious puberty

- caused by early activation of GnRH secretion - most have an idiopathic etiology - along with H&P, growth charts, and wrist Xray, morning testosterone levels in males and GnRH stimulation tests in females may be useful - most need no tx but if tx is indicated it's focus is on the underlying etiology

intimate partner violence/ IPV assessment

- certain aspects of hx or observation made during clinical encounter heightens suspicion: an inconsistent explanation of injuries, delay in seeking tx, frequent emergency department or urgent visits, missed appointments, late initiation of prenatal care, repeated abortions, med nonadherence, inappropriate affect, overly attentive or verbally abusive partner, apparent social isolation, reluctance to undress or have a genital or rectal exam - often associated with a perception of overall poor health with somatic (often gynecologic) and psychologic impact -**the assessment for IPV in pt who present with complaints or findings that suggest underlying abuse is considered a dx evaluation - **this is to be distinguished from a screening eval, which involves questioning all pts who are seen for care, regardless of whether they present with a hx or exam that raises concerns about possible abuse general principles - setting in which questioning occurs - assure that the pt feels safe and comfortable - doc should not display hesitancy, judgement, or discomfort - pt are more likely to disclose their experience of violence when: doc are ready to listen and use open ended questions, doc assure confidentiality, unless someone is in grave danger when reporting may be necessary, one or only a few questions are posed - the relational aspect of the questioning (concern, eye contact), rather than the particular words used, may be the most important factor in assisting pts with disclosure - avoid using terms like victim, abused, or battered... instead mirror the pt's words of choice like hurt, frightened, or treated badly - do not inquire about abuse in the presence of the partner, friends, or family members - do not disclose or discuss your concerns with the pts partner - do not ask the pt what they did to bring on the abuse - do not ask why the pt has not left the partner, or why they may have returned to the batterer

constitutional delayed puberty

- characterized by physiologic delay and a dx of exclusion - cause is a delay in GnRH pulse generation - these children tend to be below the 5th percentile for ht and wt - FHx may reveal that one or both parents had similar delay - catch up in adolescence reaching normal adult ht and wt

pregnancy chronic HTN management

- chronic HTN deliver at 38 wks - chronic HTN with superimposed preeclampsia: deliver at 34 wks if severe features, deliver 37 wks in absence of severe features -**recommendations are based on clinical status of the pt and fetus - **in presence of IUGR or oligohydramnios delivery may be recommended regardless of gestational age

HTN disorder in pregnancy

- chronic HTN: **elevated BP prior to pregnancy or <20 wks of pregnancy, **prior to 20 wks it is chronic HTN... after 20 wks consider preeclampsia HTN definition - mild: systolic >140, diastolic >90 - severe: systolic >160, diastolic > 110 -chronic HTN: HTN with onset before pregnancy or before 20th wk gestation, use of antiHTN meds before pregnancy persistence of HTN beyond 12 wks postpartum etiologies - idiopathic: **90%, essential HTN - vascular disorders: renovascular HTN, aortic coarctation - endocrine disorders: DM, hyperthyroidism, pheochromocytoma, primary hyperaldosteronism, hyperparathyroidism, cushing's syndrome - renal disorders: diabetic nephropathy, chronic renal failure, acute renal failure, tubular necrosis, cortical necrosis, pyelonephritis, chronic glomerulonephritis, nephrotic syndrome, polycystic kidney - connective tissue disorders: SLE

migraine headaches in pregnancy

- chronic migraines decrease during pregnancy in most pts - women with classic migraine may have their initial episode during pregnancy

men breast cancer eval

- clinical breast exam first step - mammogram, US, and MRI - biopsy all defined breast masses found

polycystic ovary syndrome/ PCOS

- clinical condition seen most frequently with androgen excess - **clinical features: abnormal menses, infertility, hirsutism, acne, obesity, insulin resistance, acanthosis nigricans, polycystic appearance to ovaries - **DDX: idiopathic hirsutism, ovarian hyperthecosis, ovarian tumors, adrenal tumors, nonclassic adrenal hyperplasia, cushing's syndrome, glucocorticoid resistance, androgen producing neoplasms -dx: with evidence of hyperandrogenism - labs: serum testosterone, androstenedione, DHEA-S, 17 hydroxyprogesterone, prolactin, TSH, lipids, glucose, insulin - transvaginal and pelvic US to eval ovaries - tx: based on reduction of CV complications, DM, obesity, psychosocial morbidities and control of acne and hirsutism by decreasing androgen levels

evaluation for female orgasmic disorder

- clinically hx: pt's perception of this dysfunction, including time and circumstances of onset, possible causes, effect on relationships, tx goals - physiologic functioning during sexual stimulation, including adequacy of lubrication, and ability to sustain states of high arousal, should be explored - inquire about contributing factors: fatigue, depression, stress, substance abuse, medical illness, relationship issues, medications such as SSRIs - PE and lab testing are non specific and dictated by hx

key tx in ovarian and testicular disorders

- common causes of precocity are benign and require no tx, careful nontherapeutic observation may be considered - tx of precocity with GnRH analogues, which reversibly inhibit gonadotropin secretion, can be used to prevent secondary sexual development and early epiphyseal fusion - hormonal therapy with hCG or GnRH can be used to increase the likelihood of testicular descent - inguinal orchiopexy is a well established procedure for palpable undescended testicle and is generally considered the standard of care for cryptorchidism in the US - present clinical practices suggests tx menopausal ssx on an individual basis, predominantly with lifestyle therapies, risk modifications, screening strategies, and nonhormonal therapy - SSRIs, clonidine, and gabapentin are recommended to tx of menopausal ssx - tibolone is effective in controlling menopausal ssx and reduces risk of fracture and breast cancer but with an increased risk of stroke - pt with PCOS require CV risk reduction, psychosocial counseling, management of subfertility and hirsutism, and insulin sensitizers and protection of endometrium with hormonal manipulation - newer selective estrogen receptor modulators/ SERMs are being used to tx depressed libido in women, which minimizes risk to the endometrium while preserving benefits to breast and bone - dx of secondary amenorrhea can be facilitated with a progesterone challenge

prenatal/ first obstetric PE

- complete PE should be performed - baseline BP, weight, and height should be recorded as part of the exam: calculating BMI facilitates counseling about the appropriate amount of weight gain over the course of pregnancy - **be familiar with physical findings associated with normal pregnancy: systolic murmur, exaggerated splitting and S3, spider angiomata, palmar erythema, linea nigra, and striae gravidarum - breast exam - pelvic exam: special attention to uterine size and shape and eval of the adnexa

barrier methods for contraception

- condom: male and female - cervical cap - diaphragm - sponge - require motivated user: use at every act of intercourse - do not contain hormones - condoms offer protection against STIs

management of asthma in L&D

- continue current asthma meds - regular peak expiratory flow measurements - continuous O2 sat monitoring - avoid analgesics and narcotic: may cause histamine release - epidural is preferred: reduced O2 consumption - fentanyl is considered safe - avoid prostaglandin F2: may cause bronchospasm - prostaglandin E2 is safe - oxytocin is safe

functional ovarian cysts

- corpus luteal or follicular - **mittelschmerz: cyclic mid cycle mild pain from physiologic rupture of follicular cyst, dermoid cysts may contain fat to hair and are managed surgically - mostly seen in women of **reproductive age, may rupture from intercourse, **postcoital hematoperitonerm has been reported from ruptured cyst - may rupture or leak fluid and/or blood, causing **peritonitis like pain, sudden u/l sharp pelvic pain, often post intercourse, right more common - **pelvic US, **CBC, **HCG, must exclude ectopic pregnancy/ appendicitis - **management depends upon severity, uncomplicated cases may be observed and usually resolve in a few days, more complicated cases with altered VS, large amount fluid on US or ten point drop in hct, should be hospitalized and eval for laparoscopic eval

intimate partner violence/ IPV risk factors

- cuts across gender, racial, ethnic, educational, and socioeconomic boundaries - occurs at individual, family, community, and wider society levels - some factors are associated with being a perpetrator of violence, some are associated with experiencing violence and some are associated with both - understanding these multilevel factors can help ID various points to target preventive interventions

obstetrics lung volumes and capacities changes

- dead spaces increases - tidal volume increases 35-50% - total lung capacity decrease about 5% due to elevation of the diaphragm - increased progesterone plays an important part in the hyperventilation of pregnancy, maternal PCO2 is slightly decreased and O2 slightly increased in a compensatory respiratory alkalosis - maternal O2 consumption increases about 20% - **dyspnea of pregnancy is common and gravid women feel that they need to take a deeper breath at times

male orgasmic disorder

- defined as ability to sustain a full erection for a reasonable duration of sexual activity but not achieve orgasm - more complete eval of CNS and PNS is warranted - drug hx: SSRI's, alcohol, PDE5 inhibitors - like females need eval contextual and partner issues

male infertility

- defined as failure to achieve pregnancy after 1 yr unprotected sex - a specific cause can be ID in 80% of couples - 1/3 is male etiology, 1/3 is female etiology, and 1/3 is both - varicocele is the most common cause of male infertility - eval includes H&P, FHx, semen analysis, testosterone levels

female infertility

- defined as failure to conceive after 1 yr of unprotected sex - fertility peaks b/n 20-24 with progressive decline until 32 - female causes of infertility include: ovarian dysfunction, tubal factors, cervical factors, uterine factors, endometriosis - tx based on underlying cause

male hypogonadism

- defined as inadequate gonadal function manifested by deficiency in gametogenesis or secretion of gonadal hormones - exist as primary or secondary hypogonadism - primary is caused by dysfunction in the testes from either chromosomal or acquired disorders - secondary is caused by an abnormality of the hypothalamic pituitary axis - clinical dx begins with hx, including sexual development milestones, current ssx, ambiguous genitalia at birth, cryptorchidism, behavioral abnormalities, anosmia, surgeries, STDs - PE is directed toward sexual characteristics, body habitus, gynecomastia - testis should be measured for length and width with and orchidometer - scrotal exam done for varicocele - serum LH and FSH levels are increase in primary and normal to low in secondary hypogonadism - Klinefelter's syndrome (47XXY) is the most common genetic cause of male infertility - Kallmann syndrome is inherited disorder which results in gonadotropin deficiency

delayed puberty

- defined as lack of thelarche by age 12 in girls - defined as no testicular enlargement by age 14 in boys - delayed puberty is classified as **constitutional (idiopathic) or **organic (gonadal, pituitary, or central causes) - eval begins with detailed hx, growth patterns/ charts, presence of secondary sexual development, diet, exercise, congenital abnormalities, neuro ssx, FHx - PE is general exam with focus on **tanner staging -lab and Xray include: CBC, LFTs, ESR, FSH, LH, estradiol, and testosterone levels, prolactin, TSH, wrist Xray and karyotype - therapy is aimed at underlying disorder - if etiology is unknown, reassurance and psychological support and re-evaluate in 4-6 mon - estrogen therapy in girls, progestin may need to be added at first breakthrough bleed or 1 yr of therapy - testosterone therapy in boys

female sexual arousal disorder

- defined as the inability to attain or maintain a genital lubrication swelling response during sexual activity - neuro and vascular etiology needs consideration when adequate genital vasocongestion and swelling do not occur but subjective arousal and lubrication are intact - to be dx: a women needs to lack or have significantly reduced sexual interest/ arousal for at least 6 month duration manifested by at least 3 of the following criteria 1. absent or reduced interest in sexual activity 2. absent or reduced sexual or erotic thoughts or fantasies 3. no or reduced initiation of sexual activity and typically unreceptive a partner's attempt to initiate 4. absent or reduced sexual excitement and pleasure during sexual activity in almost all or all sexual encounters 5. absent or reduced sexual interest or arousal in response to any internal or external sexual or erotic cues 6. absent or reduced genital or nongenital sensations during sexual activity in almost all or all sexual encounters

sexual function

- do you have any sexual concerns - if the pt has concerns about sexual activity, ask about it - direct questions help you assess each phase of sexual response: desire, arousal, and orgasm --desire phase: do you have an interest in sex -- orgasmic phase: are you able to reach climax, is it important for you to reach climax -- arousal phase: do you get sexually aroused, can you achieve and maintain an erection **for sexual function complaint, it is important to assess - is it new, chronic, or intermittent - does it cause personal distress or interpersonal difficulty - is it generalized or does it occur only in certain settings or with a specific partner **useful questions - when were you last satisfied with your sex life, describe the frequency of sexual activity and your level of desire, arousal and response at that time versus now - do you have any idea what may have occurred at that time that contributed to the problem: infertility, birth of child, depression, new meds, cancer dx, menopause, issue with partner - do you believe stress, fatigue, or limited privacy are contributing to your sexual problem - have you and/or your partner tried anything to improve your sex life

sexual hx- partners

- do you have sex with men, women, or both: use neutral nonjudgmental questions - in the past 2 months, how many partners have you had sex with - in the past year, how many partners have you had sex with - is it possible that any of your sex partners in the past year had sex with someone else

eval of the female partner for infertility- dx tests

- documentation of normal ovulatory fxn - most easily by mid luteal phase serum progesterone level (~ 1 wk before expected menses) -- for typical 28 day cycle, the test should be obtained on day 21 -- progesterone level > 3 ng/mL is evidence of recent ovulation -- mid luteal progesterone concentration is <3 ng/mL, the pt is evaluated for causes of anovulation -- minimal work up includes serum prolactin, TSH, FSH, and assessment for PCOS: low/normal FSH in PCOS, high FSH a/w ovarian failure - assessment of ovarian reserve --women over 35 yo and younger women with risk factors for premature ovarian failure --> test FSH and estradiol level - hysterosalpingogram (HSG) to rule out tubal occlusion and assess uterine cavity

travel during pregnancy

- does not adversely affect the pregnancy - it is a concern for the doc - dont want to be away from the doc if labor begins - usually no travel after 35 wks -car: proper seatbelt usage - airplane: aisle seat to be able to stretch legs and prevent DVTs, some airlines restrict travel after 36 wks, wear seatbelt always - ship/boat: seasickness

how to screen for GDM

- does not have to be fasting - after 50 g glucose drink, do not allow pt to eat or drink - **venous glucose level is drawn: venous because capillary glucose is generally higher after glucose load - ***140 or higher then.... (normal less than 140) - a **diagnostic 3 hr glucose challenge test must be performed - must be fasting - 100 g glucose - ***3 hr levels -- fasting: 95 -- 1 hr: 180 -- 2 hr: 155 -- 3 hr: 140 - if 2 levels abnormal: GDM - if fasting >105 likely A2DM ( see white's classification)

eval of the female partner for infertility- detailed hx

- duration of infertility and results of previous eval and therapy - menstrual hx: helps in determining ovulatory status, regular monthly cycles with molimina (breast tenderness, ovulatory pains, bloating) suggest the pt is ovulatory and characteristics such as severe dysmenorrhea suggest endometriosis - med, surgical, and gynecologic hx - obstetrical hx - sexual hx - FHx, with infertility, birth defects, genetic mutations, or mental retardation - personal and lifestyle hx: FEDTACOS all can affect fertility - ROS should determine whether pt has ssx of thyroid disease, galactorrhea, hirsutism, pelvic or abd pain, dysmenorhea, or dyspareunia

genito-pelvic pain/ penetration disorder evaluation

- dx is made by hx - pain during tampon insertion or the inability to insert tampon before a women becomes sexually active may be an important risk factor for genito-pelvic pain/ penetration disorder - pt reports pain and difficulty with, or inability to engage in, vaginal intercourse or digital vaginal stimulation, using tampons or vaginal contraceptives, or having a pelvic exam -defined as an involuntary, usually painful, spastic contraction of the pelvic musculature surrounding the outer 1/3 of the vagina - classified as complete, partial, or situational -pain can come before, during, or after intercourse

bisphosphonates and osteonecrosis of the jaw

- dx of bisphosphonates associated osteonecrosis of the jaw relies on 3 criteria: 1. pt possess an area of exposed bone in jaw persisting for more than 8 wks 2. pt must present with no hx of radiation tx to head and neck 3. pt must be taking or have taken bisphosphonate

dysfunctional uterine bleeding

- dx of exclusion - exclusion of all possible pathologic causes of abnormal uterine bleeding establishes the dx - most common at extremes of reproductive age: adolescents, greater than 40 - management depends on pt age

dyspareunia

- dyspareunia: difficult or painful sexual intercourse - men experience dyspareunia much less often with vaginal-penile intercourse than women - usually associated with concurrent medical illness, such as Peyronie's disease (the development of fibrous scar tissue inside the penis that causes curved, painful erections), or neuropathy -tx is based on treating the underlying physical pathology

top 10 questions that facilitate contraceptive counseling

- each woman must balance the advantages of each method against the disadvantage and side effects, and decide what they prefer - we ask the woman if she will be able to adhere to the requirements of using the method's potential side effects 1. what are your contraceptive goals? do you ever plan to get pregnant? when? 2. are you currently having sex with a male partner? 3. have you tried any contraceptive methods? if so, which ones? 4. what did you like/dislike about the methods 5. are you a good pill taker? 6. for user controlled methods, how often did you forget to use the method? 7. are there any methods you have heard about and would like to try? 8. how important is spontaneity of use? 9. is protection from STIs important considering your life situation? 10. is cost an issue? does your health insurance plan cover any contraceptive method?

goals of contraception counseling

- educate women about contraception, discuss current and future contraceptive needs, and select a contraceptive modality, if needed, thereby avoiding the risks of unintended pregnancy - discuss reproductive life plan -- ACOG: a reproductive life plan is a set of personal goals regarding whether, when, and how to have children based on individual priorities, resources, and values -- allow the doc to address any knowledge deficits, misperceptions, or exaggerated concerns about the safety of contraceptive methods, all of which are barriers to contraceptive use -- also provides an opportunity to discuss interpregnancy interval and preconceptual care - reduce unintended pregnancy -- in 2011, nearly half of the **6.1 million pregnancies in the US were **unintended -- a/w maternal depression, increased risk of physical violence to the mother, late prenatal care, reduction in breastfeeding, and financial burden -- infants born of unintended pregnancies are more likely to have birth defects, low birth weight, and poor mental and physical functioning in early adulthood -- account for most of the **1.1 million abortions performed annually in the US --for all of the reasons, the US department of health and human services healthy people 2020 objectives call for a **10% reduction in the rate of unintended pregnancy by 2020

epilepsy and seizure disorders during pregnancy

- epilepsy: two or more unprovoked seizures - new onset epilepsy is not increased by pregnancy - 95% of pts with seizures during pregnancy have a hx of the disease - due to decrease protein binding, increase plasma volume and alterations in the absorptions and excretion of drugs, serum levels of anticonvulsants drugs change - increased seizures can be from noncompliance, morning sickness, hyperemesis gravidarum, loss of sleep

vaginal dryness

- epithelial lining of vagina and urethra are estrogen dependent tissues and estrogen deficiency leads to thinning of the vaginal epithelium - results in vaginal atrophy (atrophic vaginitis), causing ssx of vaginal dryness, itching, and dyspareunia - ssx of vaginal atrophy are progressive and worsen as time passes - on exam, vagina appears pale, with lack of normal rugae - external genitalia may show scarce pubic hair, diminished elasticity and turgor of the vulvar skin, introital narrowing or decreased moisture, and fusion or resorption of the labia minora

male sexual dysfunction

- erectile dysfunction - premature/ rapid ejaculation - male orgasmic disorder - dyspareunia

initial OB visit hx

- establish EDD, sometimes see EDC - medical Hx: HTN, DM, thyroid, indoor cats (toxoplasmosis) - surgical hx: appendectomy, cholecystectomy, myomectomy (removal of uterine fibroids), other uterine surgery, may necessitate need for C section - obstetrical hx: prior pregnancy (length of gestation, birth weight, fetal outcome, length of pregnancy, fetal presentation, type of delivery, complications), recent pregnancy, hx of miscarriage, hx of preterm deliveries, hx of C section - GYN hx: abnormal pap smears, pelvic infections, STDs

menses

- estrogen and progesterone causes positive feedback - FSH and LH production falls - spiral arteries become coiled and have decreased blood flow: contract and relax causing sloughing of functionalis layer and menses

**organic delayed puberty

- etiologies are pituitary dysfunction or hypogonadotropic hypogonadism - differentiates of the organic forms from constitutional may be difficult to establish in certain pts - no single study or imaging technique will differentiate these -hypogonadotropic hypogonadism presents with low FSH and LH as result of defective GnRH pulsation - GnRH pulsation defects can be due to anorexia nervosa, excessive weight loss, extreme exercise, tumors, head trauma - hypogonadotropic hypogonadism is usually caused by gonadal failure, will see increase levels of gonadotropins and decrease levels of sex steroids

erectile dysfunction evaluation

- eval involves good hx and physical exam - increase CV risk: ****if it is bad for the heart, it is bad for the penis - PE should focus on vascular, neurological, and endocrine systems - no specific lab test; general testing BUN, creatinine, TSH, PSA, and testosterone may be indicated

abnormal puberty

- eval should begin if signs of puberty develop in girls younger than 8 or in boys younger than 9 - dx of true puberty and pseudo puberty should be differentiated - eval includes H&P, growth charts and wrist Xray - if true puberty suspected, consider CT or MRI of head to rule out CNS lesions

eval and tx for abnormal bleeding in perimenopausal women

- eval: endometrial biopsy to exclude endometrial hyperplasia or cancer tx - nonsmokers can be tx with hormonal contraceptives for cycle control - smokers: avoid estrogen due to thrombotic risk, use cyclic progestin for monthly withdrawal bleed

prenatal/ first obstetric life style advice

- fatigue: advise to rest when tired and reassured that the fatigue usually abates by the 4th month of pregnancy - should be advised to continue exercise unless HTN, PTL (preterm labor), ROM (rupture of membranes), IUGR (Intrauterine growth restriction), and incompetent cervix, persistent second or third trimester bleeding, or medical conditions that severely restrict physiologic adaptions to exercise during pregnancy: **any type of exercise involving the potential for loss of balance or even mild abd trauma should be avoided - travel is acceptable under most circumstances - increased, unchanged, and decreased levels of sexual activity can all be normal during pregnancy

female sexual dysfunction

- female sexual desire and arousal disorder - female orgasmic disorder -genito-pelvic pain/ penetration pain: vaginismus, dyspareunia

positive manifestations of pregnancy

- fetal heart tones: can be heard using fetal doppler at 10 wks, usually 150-160 bpm in the 1st and 2nd trimester, slows to 120s in the 3rd trimester due to influence of the vagus nerve maturing - palpation of the fetus: can be palpated about 22 wks through the abd wall, movement can be palpated at 18 wks by examiner - US exam: very useful in pregnancy, cardiac activity at 5-6 wks, limb buds at 7-8 wks, finger and limb movements at 9-10 wks

fetal thyroid function during pregnancy

- fetal hypothalamic pituitary thyroid axis becomes functional at 12 wks - before 1st trimester, the fetus is dependent on local monodeiodination of transferred maternal T4 and T3 - this transferred T4 seems to be important for fetal growth, esp early brain development - **maternal hypothyroidism is linked to poor cognitive development - TSH does not cross the placenta - iodine crosses the placenta and fetal thyroid starts concentrating it by **12 wks - excess iodine causes fetal goiter and hypothyroidism - at birth, there are dramatic changes in the thyroid, the profile reaches normal values w/in hrs - normal thyroid levels are crucial for subsequent brain maturation and intellectual development

weight gain in pregnancy distribution of weight

- fetus accounts for **1/3 of normal weight gain - placenta, amniotic fluid, and uterus for 650-900 g - interstitial fluid and blood volume for 1200-1800 g - breast enlargement for 400 g - remaining 1640 g or more is largely maternal fat

genito-pelvic pain/ penetration disorder tx

- few studies exist on tx - sex therapy may be helpful - if vaginal mm tightening or spasm is present, relaxation techniques may help - pt may begin self tx with size graded plastic or silicone vaginal dilators, gradually teaching her vagina to remain relaxed and received nonpainful, self controlled penetration - biofeedback may be helpful - OMM may prove useful in relaxation of pelvic mm

obstetrics clotting factors changes

- fibrinogen and factor VIII increase significantly - factors VII, IX, X, and XII increase to a lesser extent - factor V only mildly increased - factor XIII (fibrin stabilizing factor) is dramatically reduced - protein S decreases

preconception counseling- core interventions

- folic acid supplementation and intake of folate fortified food: 400-800 mcg daily, can reduce NTD - diabetic pt: glycemic control to reduce risk of miscarriage and embryopathy, ACE inhibitors/ARBs/ statins should be discontinued - control of phenylalanine levels in women with PKU - abstinence from alcohol and illicit drugs - smoking cessation - UTD on vaccines: live vaccines should be given at least 1 month prior to pregnancy - weight reduction or gain to achieve normal BMI - med change or discontinuation to avoid teratogens - avoidance of environmental teratogens - disease optimization - behavioral changes

herpes simplex virus/ HSV

- genital HSV common worldwide - **mostly genital herpes infection - HSV1 may cause similar clinical findings - **painful but not always ulcerations of the genitalia - **vesicles on erythematous base - **accompanied with lymphadenopathy that is tender, soft and usually b/l; **fever and malaise common - **dx of primary episode: tzanck smear, clinical, viral cultures, ab testing - tx: antivirals such as acyclovir, famciclovir, or valacyclovir - **recurrent cases: grouped vesicles w/o adenopathy or systemic complaints, frequent recurrences may benefit from daily suppressive therapy over suppressive therapy for episodic outbreaks - **less transmission to partners with daily therapy OR with condom use

fetal HR variability**

- good indicator of healthy nervous system - oscillation of the FHR around the baseline with amplitude of 6-25 beats/min categories - absent: amplitude range is undetectable... BAD - minimal: amplitude range is detectable, but 5 or less beats/ min... hypoxia, sleepy baby, narcotics - moderate: amplitude is 6-25 beats/min... GOOD - marked: amplitude range is greater than 25 beats/min... fetal hypoxia

sexual hx- past hx of STIs

- have you ever had an STI - have any of your partners had a STI - additional questions to ID HIV and viral hepatitis risks: have you or any of your partners ever injected drugs, have you or any of your partners exchanged money or drugs for sex, is there anything else about your sexual practices that i need to know about

sexual hx- practices

- have you had vaginal sex: if yes then do you use condoms - have you had anal sex: if yes, do you use condoms, ask about diarrhea, rectal bleeding, and anal itching and pain - have you had oral sex: if yes, ***ask about ssx such as sore throat - for condom answers -- if never: why not --if sometimes: in what situations do you not use condoms

preconception counseling- interventions

- health promotion education - counseling related to reproductive health risks - optimizing the control of medical disorders - referral to specialized care - can reduce the occurence of congenital abnormalities, congenital disease, impaired or excessive fetal growth, and variety of pregnancy complications (preterm birth, abruptio placenta)

major goal of prenatal care and the components involved in achieving this objective

- help ensure the birth of a healthy baby while minimizing risk to the mother - early, accurate estimation of gestational age - ID pregnancies at increased risk for maternal or fetal morbidity and mortality - ongoing eval of maternal and fetal health status - anticipation of problems with intervention to prevent or minimize morbidity - health promotion, education, support, and shared decision making

baseline preeclampsia labs

- hemoglobin/ hematocrit: hemoconcentration but remember pregnancy causes hemodilution and anemia - platelets: thrombocytopenia may be present - creatinine: a measure of kidney function, as vasoconstriction starts then GFR will decrease, UOP will decrease, creatinine will increase... but remember that creatinine is usually lower in pregnancy .5 mg/dL - uric acid: hemolysis and decreased kidney tubular function will increase uric acid - AST: liver enzymes may be elevated - LDH: liver enzyme may be elevated

unintended pregnancy

- high rate of unintended pregnancy in US **highlights the need for effective contraceptive education - a survey study of 7800 women who had unprotected intercourse that led to an unintended pregnancy: -- **reported the following reasons for unprotected intercourse: believed they could not get pregnant at time of conception, did not really mind if they got pregnant, stated their partner did not want to use contraception, cited side effects, believed they or their partner were sterile, cited access problems, selected other - **the fact that 1/3 of these women did not perceive themselves to be at risk for becoming pregnant emphasizes the need for more and effective education

IUD benefits

- highly efficacious - easy to use - forgettable contraception: does not require remembering a schedule - safe for most women, including teen and nulliparous women - alternative to surgical sterilization - private and does not interfere with the spontaneity of sex - long acting - rapidly reversible - few side effects - few contraindications - avoidance of exogenous estrogen - reduced cost with long term use - reduction in risk of cervical cancer

sleep disturbance

- hot flashes are more common at night and associated with arousal from sleep - but don't forget other possible causes: anxiety, depression, sleep apnea, restless leg syndrome

eval for primary amenorrhea

- hx - PE with focus on developmental of secondary sexual characteristics - always rule out pregnancy - labs: FSH, LH, TSH, and prolactin levels - in pt w/o a uterus, serum testosterone and karyotyping should be done - normal or reduced FSH: chronic anovulation, functional hypothalamic amenorrhea, or PCOS - increased FSH and breast development: ovarian failure - uterus present and normal secondary sex characteristics: thyroid function should be checked

guidelines for pharm tx in postmenopausal women and men > 50 yo

- hx of hip or vertebral fx - T score < -2.5 at the femoral neck or spine, after appropriate eval to exclude secondary causes - T score b/n -1 and -2.5 at the femoral neck or spine, and a 10 yr probability of hip fx >3% or a 10 yr probability of any major osteoporosis related fracture >20% based upon the US adapted WHO algorithm

fat necrosis of breast

- hx of trauma to the breast common - firm, irregular mass - skin or nipple retraction common - gradually disappears

vulvovaginal candidiasis vaginitis dx

- hx, ssx - use of KOH or saline wet prep slide **visualize pseudohyphae/ budding yeast - pH is normal, **4-4.5, if **pH >4.5 consider concurrent bacterial vaginitis or trichomoniasis infection - culture not useful in routine cases - **many women now use OTC tx when they have ssx of VVC, but this tx can complicate the actual dx

obstetrics skin anatomic changes

- hyperpigmentation is one of the well recognized skin changes of pregnancy, which is manifested in the **linea nigra and melasma, the mask of pregnancy - melasma is exacerbated by sun exposure, develops in up to 70% of pregnancies and is characterized by an uneven darkening of the skin in the centrofacial malar area - the hyperpigmentation is probably because of the elevated concentration of melanocyte stimulating hormone and/or estrogen and progesterone effects on the skin -**striae gravidarum consist of bands or lines of thickened hyperemic skin. these stretch marks begin to appear in the 2nd trimester on the abd, breasts, thighs, and butt - decreased collagen adhesiveness and increased ground substance formation are characteristically seen in this skin condition; a genetic predisposition appears to be involved because not every gravida develops these skin changes - effective tx has yet to be found -other common changes include spider angiomas, palmar erythema, and cutis marmorata (mottled appearance of skin secondary to vasomotor instability) -the development or worsening of varicosities accompanies nearly 40% of pregnancies - increased venous pressure in the lower extremities, which dilates the veins in the legs, anus (hemorrhoids) and vulva - nails become brittle and can show horizontal grooves (Beau's lines) - thickening of the hair during pregnancy

menopause ddx

- hyperthyroidism - pregnancy - hyperprolactinemia - meds - carcinoid - pheochromocytoma - underlying malignancy

pregnancy vaccines

- ideally women should be vaccinated against preventable disease in their environment prior to conception according to the recommended adult immunization schedule - flu season: should receive the inactivated flu vaccine regardless of trimester - Tdap to all pregnant women in each pregnancy b/n 27 -36 wks of gestation -pregnant women with comorbidities or exposure that place them at high risk for hep A/B, pneumococcal, H influenzae b, or meningococcal infections can receive these - high risk areas cannot be avoided, inactivated travel vaccines (polio, typhoid fever) can be admin prior to travel - HPV vaccine during pregnancy is avoided -*** avoided: MMR, varicella, yellow fever, polio, HPV

ACOG guidelines for DXA and FRAX

- if initial BMD indicates low bone mass use FRAX to see if high risk for fx - if FRAX does not indicate a high risk: --DXA every 15 yrs for woman older than 65 w/ normal BMD/ T score >-1.5 --5 yrs DXA T score from -1.5 to -2.49 --1 yr DXA T score b/n -2.0 and -2.49 - the fracture risk assessment tool should continue annually to monitor important effect of age on fracture risk

etonogestrel contraceptive implant

- implanon, nexplanon - among the most effective contraceptives - single rod progestin contraceptive place subdermally in the inner upper arm for long acting (3 yrs) reversible contraception - most women are candidates, high risk of unintended pregnancy - standard contraindication: known or suspected pregnancy, hx of thrombosis or thromboembolic disorders, hepatic tumor or active liver disease, undx abnormal genital bleeding, known or suspected breast cancer or hx of breast cancer, hypersensitivity to any component of the method - brief office procedure: less than 2-3 min - can be inserted any time - abstinence or back up contraception is suggested for 7 days after insertion or if implant is inserted >5 days since the beginning of the pt's last menstrual period - unscheduled bleeding is the most common side effect and reason for discontinuation - can be removed at any time

preconceptional care

- important component of women's health - opportunity to max maternal and fetal health benefits before conception - issues of potential consequences to a pregnancy such as medical problems, lifestyle, or genetic issues should be investigated and interventions devised prior to pregnancy - specific recommendations include folic acid for prevention of NTD - strict blood sugar control in DM - general management of any medical problems - focus on: DM, HTN, asthma, thyroid disorders, neuro considerations

obstetrics heart murmurs and rhythm

- in 90% of pregnancies, increase physiologic systolic ejection murmur (flow murmur)

female orgasmic disorder

- inability to reach orgasm when desired, may be primary or secondary - for dx: women must have experienced a marked delay in orgasm, marked infrequency of or absence of orgasm, and markedly reduced intensity of orgasmic sensations over a 6 month time frame - some women feel they have primary disorder because they do not reach orgasm solely with vaginal intercourse - basic description of physical orgasm ( pleasurable sensation in the genital area and contractions of the vagina followed by a feeling of physical and psychological relaxation) may facilitate discussion of orgasm - many women prefer simultaneous vaginal and clitoral stimulation, oral genital sex, or clitoral stimulation alone to have an orgasm and do not have an orgasmic disorder - the individual must express clinically significant distress regarding the diminished orgasmic sensations for an orgasmic disorder to be dx - inquire about prior or current experiences of violence, abuse, and victimization - inquire about negative messages regarding sexuality or strict religious or cultural prohibitions - books and films often overstate the female orgasm

severe maternal morbidity/ SMM

- included unexpected outcomes of L/D that result in significant short or long term consequences to a woman's health - steadily increasing in recent yrs and affected **more than 50,000 women in US in 2014 - maternal age, pre pregnancy obesity, preexisting chronic medical conditions, increase in C sections - the consequences of the increasing SMM prevalence and to the health effects for the women, are wide ranging and include **increased medical cost and longer hospital stays

ovulatory abnormal vaginal bleeding in reproductive age women

- includes menorrhagia, polymenorrhea, oligomenorrhea, intermenstrual bleeding - menorrhagia associated with structural lesions (uterine leiomyomas, endometrial polyps, hyperplasia), coagulation disorders, liver failure, chronic renal failure

breast cancer in women risk factors

- increased age - nulliparity or late first pregnancy - positive personal or FHx - BRCA 1 or BRCA 2 mutation - white race - early menarche - late menopause - diethylstilbesterol (DES) exposure - hormone therapy - alcohol - obesity - radiation exposure

hydralazine for pregnancy HTN management

- increases cGMP levels, decreasing the phosphorylation of smooth mm myosin light chains, this results in blood vessel relaxation, it dilates arterioles more than veins - requires the endothelium to provide NO - is a first line choice for IV use for acute management - start with 5-10 mg IV q 20 min, may give up to 120mg

menopausal hormone therapy/ MHT counseling: pt discussion

- indication for prescription hormones: vasomotor ssx, genital atrophy, bone preservation - contraindications reviewed: active breast/ uterine cancer, thromboembolism, liver/gallbladder/triglyceride disease - individualized therapy: lowest dose for shortest time - risks/benefit

N/V of pregnancy tx

- initially vit B6/ pyridoxine 25 mg PO - doxylamine 12.5mg TID or QID - promethazine (phenergan) 25 mg PO - ondansetron (zofran) 4 mg PO

injectable (depo-provera)

- injectable, progestin only contraceptive - provides highly effective, private, relatively long acting (3 month), reversible contraceptive - use eliminates both the need for user action daily or near the time of sexual intercourse and the need for partner cooperation - ideal time to initiate DMPA is w/in 7 days of onset of menses: quick start or depo now approach - side effects: unscheduled bleeding, can trigger H/A, weight changes - association with decreased bone mineral density beneficial effects on comorbid conditions - reduction in heavy menstrual bleeding, dysmenorrhea, or iron deficiency anemia - dysmenorrhea related to endometriosis - use in anticoagulated women - endometrium protection - reduction in PID - reduction in ectopic pregnancy - making hygiene easier: special needs pt - reduction in sickle cell crisis - possible reduction in seizures - lack of drug interactions

**insulin during L&D for GDM

- insulin is withheld in morning - when glucose falls below 70, IVF's switched from NS to D5LR - hourly FSG: target 100 - if FSG > 100, start insulin infusion at 1.25 units/hr, and titrate accordingly - check ketones every void

menopausal dx for women 40 and under

- irregular menses and menopausal ssx -> complete eval - atypical hot flashes: eval for other disorders such as carcinoid, pheochromocytoma, or underlying malignancy is indicated - heavy bleeding or prolonged bleeding should undergo same eval as any premenopausal woman

menopausal dx for women 40-45

- irregular menstrual cycle, w/ or w/o menopausal ssx -> same endocrine eval to any woman with oligo/amenorrhea - lab testing to exclude the following: --pregnancy: serum hcg -- hyperprolactinemia: serum prolactin -- hyperthyroidism: serum TSH - **err on the side of caution

normal pregnancy

- is the maternal condition of having a developing fetus in the body - embryo: the human conceptus from fertilization through the 8th wk of pregnancy - fetus: from the 8th wk until delivery - for obstetric purposes, the duration of pregnancy is based on gestational age: the estimated age of the fetus is calculated form the first day of the last menstrual period, assuming a 28 day cycle - **gestational age: is expressed in completed wks -**fetal age/ developmental age: is the age of the offspring calculated from the time of implantation - **gravid: means pregnant, and gravidity is the total number of pregnancies - **parity: state of having given birth to an infant or infants weighing 500g or more, alive or dead; if weight is unknown then an estimated duration of gestation of 20 completed wks or more - from a practical clinical viewpoint, a fetus is considered **viable when it has reached a gestational age of 23-24wks and a weight of 500g or more - half of infants 23-24 wks survive - with regard to parity, a multiple birth is a single parous experience

preconception counseling- risk assessment

- key task -> obtain a thorough hx age - as maternal age increases so does the risk of infertility, fetal aneuploidy, miscarriage, gestational DM, preeclampsia, still birth - paternal age: decreased fertility, semen quality, sexual function and coital frequency, various concerning developmental outcomes in offspring medical hx - chronic medical problems: including obesity - med known to be teratogens - reproductive hx - genetic conditions and family hx - substance use: tobacco, alcohol, non prescribed drugs - infectious disease and vaccinations - nutrition, exercise, and weight management - environmental hazards and toxins - social and mental concerns

osteoporosis PE

- kyphosis - early clinical sign of osteoporosis is loss of height greater than 1.5 in due to vertebral compression fractures, which may be accompanied by acute or chronic back pain

nipple discharge galatorrhea

- lactation not associated with childbearing - elevated levels of prolactin result in milk production - usually b/l - discharge is milky - no mass present

infant mortality

- leading causes of infant mortality (death from birth to 1 YO): congenital malformations, prematurity related conditions - perinatal death: occurs at any time after 22 wks gestation through 28 days after delivery - perinatal mortality rate: the sum of fetal stillbirths and neonatal deaths, pre term birth is the leading cause of perinatal morbidity and neonatal mortality

smoking during pregnancy

- low birth weight infants - intrauterine growth restriction/ IUGR - perinatal morbidity and mortality - placenta previa - placenta accreta - placental abruption - smoking cessation aids are better than actually smoking but still have same risks - if no cessation, reduction is helpful - **if pt can stop smoking by 15 wks, they have an equal chance of having a full term, normal birth weight infant

female sexual disorders key points***

- low sex drive is the most common sexual problem reported by women - the cyclic model of sexual functioning postulates that arousal may be the initial trigger for a women's sexual encounter, not desire - ovarian androgens may play role in female sexual drive - female sexual interest/ arousal disorder in the DSM5 recognizes the interaction b/n desire and arousal as the trigger for a woman's sexual response - psychosocial interventions may be efficacious for the tx of female sexual dysfunction - SSRI antidepressants delay or inhibit orgasm in women - women may believe they have primary inhibited orgasm disorder because they do not reach orgasm solely with vaginal intercourse - in most cases of orgasmic dysfunction, no specific physical exam or lab testing is necessary - vaginismus is an involuntary, usually painful, spastic contraction of the pelvic mm involving the outer 1/3 of the vagina and is complete, partial, or situational

hypoactive sexual desire disorder

- low sex drive most frequent sexual problem reported - can be general, situational, acquired or lifelong - **defined as a recurrent, consistent lack of ability to experience any desire or arousal - female sexual desire is a complex interaction of psychological, social, biological, interpersonal, and environmental factors - in women 29-49, it is about 3x more likely in surgical postmenopausal women than premenopausal women - in women >50 yo no significant difference in HSDD with surgical or natural postmenopause - other medical conditions can affect sexual desire - medications can also affect sexual desire - fear of pregnancy or sexually transmitted disease can affect desire

Asthma in pregnancy goals of tx

- maintain normal or near normal pulmonary function to allow adequate oxygenation - prevent exacerbations of asthma - allow the pt to maintain usual activities - portable peak flow meter: objectively eval asthma severity, PEF rate correlates well with FEV1 and allows the detection of worsening at an early stage before serious ssx appear, allows eval of response to tx while the pt is still at home - measures pt can take to manage their asthma: avoid environmental triggers, quit smoking, flu vaccine, continue allergy shots, tx rhinitis and sinusitis

normal sexual development

- major determinants of sex development can be divided into three components: chromosomal sex, gonadal sex/ sex determination, phenotypic sex/ sex differentiation - 1:4000 babies require investigation of ambiguous genitalia - chromosomal sex, defined by karyotype, describes the X and/or Y chromosome complement that is established at the time of fertilization - gonadal sex refers to the histologic and functional characteristics of gonadal tissue as testis or ovary - embryonic gonad is bipotential and can develop into either a testis or an ovary depending on which genes are expressed - sexual development is driven by the hypothalamic pituitary axis - the process is the pulsatile release of GnRH from the hypothalamus - sexual differentiation in humans is controlled by genetics, environment, and hormones - puberty refers to a physiologic transition phase b/n childhood and adulthood; characterized by a growth spurt and development of secondary sexual charcteristics - the growth spurt is a complex hormonal event in which GH, thyroid hormones and sex steroids play a major role - sexual maturation of females start with breast development at around age 11 and followed by pubic hair development and menses - males begin with scrotal corrugation and testicular enlargement at around 11.5 yrs then followed by pubic hair and penis growth - the development is based on staging by marshall and tanner

importance of screening for breast cancer in women

- majority of breast cancers in US are dx as a result of an abnormal screening study - clinical breast exam, mammography, MRI, and breast self awareness are the modalities for screening asymptomatic women

gynecomastia

- male breast enlargement - smooth, firm, mobile, tender disk of breast tissue behind areola - usually nontender - u/l or b/l - result of increased body fat, hormone imbalance, meds

bacterial vaginosis prevention, counseling, and education**

- may be sexually associated but not classed as STD - abstinence - avoid douching - limit number of sex partners - use med as prescribed - have male partners use condoms

fibroadenoma of breast

- may occur in girls and women of any age during their reproductive years - usually b/l - may be single or multiple - round, ovoid - rubbery, discrete, mobile - non tender, 1-5 cm in diameter - size does not fluctuate with menstrual cycle

hot flashes

- mediated by thermoregulatory dysfunction at the level of hypothalamus and are induced by estrogen withdrawal - begin as sudden sensation of heat centered in upper chest and face that rapidly becomes generalized - lasts from 2-4 minutes - often associated with profuse perspiration and occasionally palpitations, and is sometimes followed by chills and shivering, and a feeling of anxiety - usually occurs several times a day - ~80% more than one year - stop spontaneously w/n 4-5 yrs of onset: some will have hot flashes that persist for many years

perimenopause

- menopausal transition: after reproductive years but before menopause - ~ 4 yrs prior to full menopause - marked hormonal fluctuations: accompanied by hot flashes, sleep disturbances, mood ssx, and vaginal dryness - changes in lipids and bone loss begins

abnormal bleeding in postmenopausal women

- menopause is defined as 12 months w/o menstrual period - after than any bleeding is abnormal - main concern is endometrial carcinoma with 10-20% of all bleeding due to malignancy - eval: pelvic US, endometrial biopsy

contraceptive methods

- methods themselves may be categorized into reversible methods used before intercourse and those methods that are permanent - efficacy of a method is estimated by first year failure rates measured under 2 different conditions: correct and consistent use (reflecting a method's full potential), typical use (estimates are derived from surveys of everyday, real world users)

obstetrics renal anatomic changes

- mild hydronephrosis: the length of the kidneys increases by 1-1.5 cm, with a proportional increase in weight - mild hydroureter: the ureters are dilated above the brim of the bony pelvis with more prominent effects on the R, the ureters elongate, widen, and become more curved - the entire dilated collecting system contains up to 200 mL of urine, which predisposes to **ascending urinary infections several factors contribute to the hydronephrosis and hydroureter of pregnancy - progesterone causes hypotonia of ureteral smooth mm - enlargement of the ovarian vein complex in the infundibulopelvic ligament may compress the ureter at the brim of the bony pelvis - hyperplasia of smooth mm in the distal 1/3 of the ureter may cause reduction in the luminal size, leading to dilatation in the upper 2/3 - the sigmoid colon and dextrorotation of the uterus likely **reduce compression and dilatation of the L ureter relative to the R

obstetrics WBC changes

- mild leukocytosis is normal in pregnancy - prepregnancy levels of 4300-4500 to late trimester levels of 5000-25000 - at delivery, marginalization can occur, and counts can be seen as high as 20000-25000

exercise during pregnancy

- moderate exercise is fine in normal pregnancy - if not already physically active it is best not to start training for a marathon during pregnancy - helps reduce backaches, constipation, bloating, and swelling - may help prevent or tx **gestational DM -increases energy - improves mood - improves posture - promotes mm tone, strength, and endurance - helps you sleep better

fibrocystic breast condition

- most common breast lesion - ages 30-50 - usually b/l - often multiple masses - usually tender - size may fluctuate - worse before menses

hypothyroidism

- most common cause is autoimmune thyroid disease, hashimoto's thyroiditis - second most common cause is s/p radioactive iodine or thyroidectomy - elevated TSH, low free T4 -ssx: fatigue, sleepiness, cold intolerance, mental slowing, hair loss, dry skin, hoarseness, constipation, mm aching, paresthesias - who to screen: high risk pregnancy, prior hx of thyroiditis, T1DM, presence of a goiter

anovulatory causes of abnormal vaginal bleeding in reproductive age women

- most common cause of abnormal bleeding at this stage - majority due to hypothalamic abnormalities or PCOS - unpredictable, cannot be classified by any one type of bleeding pattern - due to lack of ovulation, produces an unopposed estrogen state - lack of progesterone causes irregular endometrial growth and nonuniform bleeding

nipple discharge

- most common causes: duct ectasia, intraductal papilloma, galactorrhea, malignancy - **spontaneous nipple discharge always requires eval

vulvovaginal candidiasis vaginitis clinical presentation and ssx

- most common ssx: **vulvar pruritus - vaginal discharge is **thick, white, and curdy... cottage cheese like, but many times be watery and thin in some pt - may cause external and internal **erythema, irritation, excoriations, and the occasional erythematous satellite lesion to non-vaginal skin tissue - dyspareunia and external dysuria is not uncommon - **cervix is not involved nor is there an odor to the discharge - **discharge adherent to vaginal walls

inflammatory carcinoma

- most malignant form of breast cancer - <3% of all cases - erythematous, edematous, warm - no distinct mass - often mistaken for infection

dual energy X ray absorptiometry/ DXA

- most widely used method for measuring BMD because it give very precise measurements at clinically relevant skeletal sites - DXA of the spine, hip, and forearm is the only method for dx of osteoporosis in the absence of a fragility fracture and the best method for monitoring changes in BMD over time - accuracy and precision are excellent -radiation exposure is low

female sexual arousal disorder tx

- no approved FDA tx - estrogen therapy improves vaginal dryness but may not affect sexual interest - for women w/in 5 yrs of amenorrhea (early menopause), tx with estrogens alone or in combo with progesterone was associated with a small to moderate improvement in sexual function, particularly in pain - lack of ovarian androgens is implicated in sexual interest and arousal, testosterone replacement has been investigated - RCT of sildenafil in postmenopausal women with SSRI associated sexual dysfunction showed an improvement in delayed orgasm and arousal/ lubrication but no improvement in desire

baseline fetal HR

- normal baseline FHR ranges from 110-160 - is a function of the autonomic nervous system - baseline change is interpreted as one that persists for 10 min or more and occurs b/n or in the absence of contractions - FHR of less than 110 is considered bradycardia: stressful events such as hypoxia, uterine contractions, and head compression - FHR greater than 160 is defined ad tachycardia: seen with certain maternal and fetal conditions, such as chorioamnionitis, maternal fever, and fetal tachyarrhythmias

human placental lactogen

- normal in any pregnancy - present only in pregnancy - levels risk to term until reach 5-7 pg/mL - causes lipolysis and increases FFA for infant's nutrition - causes increase insulin resistance to increase BG for infant's nutrition

tx for abnormal bleeding in reproductive age women

- not necessary unless pt wants to be pregnant, is bothered by bleeding pattern or has systemic ssx from anemia - anovulation is an unopposed estrogen state and requires tx with some type of progesterone to reduce risk of endometrial hyperplasia or carcinoma (should have progesterone induced withdrawal bleed at least 4 x a yr) - heavy bleeding with signs of hypovolemia: admit to hospital for tx with IV estrogen to stop bleeding or surgical procedure/ D&C... if stable, outpt tx with high dose OCP, estrogen or progesterone

postpartum thyroid dysfunction

- occurs in up to 5% of all women - often recurs in subsequent pregnancies

contraceptive vaginal ring

- offers the same benefits as OCs, but has the advantage that daily user compliance is not required - the ring is left in place for three wks and then removed for a single ring free wk: periodically check to ensure the ring is in place - initiation and use: BP should be measured but no other PE or labs needed, first day of menses provides assurance that woman is not pregnant but can be inconvenient, alternatively new users can start at any point (quick start method) as long as pregnancy is excluded, CDC recommends back up if inserted > 5 days from the beginning of menstrual bleed - effective in 24 hrs - can remove for up to 3 hrs: if ring is removed or expelled for > 3 hrs then back up contraceptive is needed for 7 days - after removal of ring, resumption of ovulation is rapid ~13-19 days - adherence with vaginal ring is similar to that with OCs - cycle control is a benefit of all combined hormonal contraceptive methods: equivalent or superior to OCs and the transdermal patch - systemic side effects are generally similar to those of OC, the ring is associated with more vaginal ssx: do not require tx and do not appear to result in discontinuation of ring - carries the same risks as other combined hormonal methods

infertility tx

- once the cause is ID, therapy aimed at correcting reversible etiologies and overcoming irreversible factors - couple counseled on lifestyle modification to improve fertility: weight reduction, smoking cessation, reducing excessive caffeine and alcohol consumption, appropriate timing and frequency of coitus (every 1 to 2 days around the expected time of ovulation or according to an ovulation predictor kit) - ovulation induction agents: clomiphene, aromatase inhibitors, gonadotropin therapy - metformin for PCOS - dopamine agonists for hyperprolactinemia - in vitro fertilization/ IVF - oocyte/ sperm donation - surgical correction

intimate partner violence/ IPV epidemiology- US

- only a small percentage of episodes are reported - in women of US: 20% of sexual assaults, 25% of physical assaults, and 50% of stalking episodes are reported - even fewer incidents against men are reported - most studies ask about violence exclusively in the context of heterosexual relationships - IPV in 2007 accounted for 14% of all homicides in us

preconceptional care- HTN

- optimize BP - baseline proteinuria and labs -methyldopa is first line agent and safe - other safe meds: CCB, vasodilators, beta blockers (but don't use with maternal asthma or CHF) - **ACE inhibitors/ ARBs cause fetal renal tubular dysplasia, oligohydramnios, neonatal renal failure, lack of cranial ossification, intrauterine growth restriction - **diuretics: decreases maternal vascular volume, decreases placental perfusion

preconceptional care- thyroid

- optimize thyroid levels - levothyroxine and propylthyrouracil/PTU are safe

combined hormonal contraception mechanism of action

- oral contraceptives have several mechanisms - the most important mechanism for providing contraception is inhibition of the midcycle LH surge, so that ovulation does not occur: combined oral contraceptive are potent in this regard, but progestin only pills are not

men breast cancer clinical pictures

- painless lump is primary complaint - retraction, erosion, ulceration - hard, ill defined mass - nipple discharge in men is associated with breast cancer nearly 75% of the time

probable manifestations of pregnancy

- pelvic organ changes: **chadwick's sign is a bluish or purplish discoloration of the vagina and cervix, **leukorrhea is normal increase in vaginal discharge, **hegar's sign is widening of the isthmus about 6-8 wks, bones and ligaments of the pelvis - abdominal enlargement: **fundal height - uterine contractions

erectile dysfunction tx

- phosphodiesterase 5 inhibitors: viagra, cialis - prostaglandin E1: MUSE, caverject - vacuum constriction device - apomorphine - yohimbine - testosterone supplementation - ED associated with psychological origin may benefit from psychotherapy - OMM may be helpful

ovulatory abnormal menstrual bleeding

- polymenorrhea: a luteal phase disorder (decreased progesterone) associated with a short follicular phase - oligomenorrhea: due to prolonged follicular phase - intermenstrual bleeding: due to cervical pathology (displasia or infection) or IUD

abnormal vaginal bleeding most common causes for reproductive age women

- pregnancy complications - anovulatory disorders - benign pelvic pathology

solitary thyroid nodule during pregnancy

- pregnancy does not affect the growth rate or prognosis of thyroid cancer - see algorithm for work up of palpable thyroid nodule in current obst and gyn

prenatal/ first obstetric follow up visits

- prenatal visits scheduled every: 4 wks until 28 wks gestation, 2-3 wks until 36 wks, weekly until delivery - **should be tailored to the needs of individual pt - evaluate BP, wt, urine protein and glucose, uterine size for progressive growth, and fetal heart rate - after the woman reports quickening (first sensation of fetal movement, on average at 20wks) and at each subsequent visit, she should be asked about fetal movement - b/n 24-34 wks, women should be taught warning ssx of PTL (preterm labor) - late second trimester: should also be taught to recognize the warning ssx of preeclampsia - near term: instructed on the ssx of labor - screened for depression early in pregnancy, during the third trimester, and again postpartum -starting at 28 wks, systematic exam of abd should be carried out each prenatal visit to ID the lie, presentation, and position of the fetus - universal or selective screening for gestational DM should be performed b/n 24-28 wks: risk factors for selective screening include FHx of DM, previous birth of a macrosomic, malformed, or stillborn baby, HTN, glycosuria, maternal age >30, or previous gestation DM - +/- repeat measurement of H/H (hemoglobin and hematocrit) levels early in the 3rd trimester - +/- repeated STI at 32-36 wks - CDC recommends universal screening for colonization of group B strep at 35-37 wks gestation

**eclampsia and its management

- presence of tonic clonic seizures - estimated incidence of eclampsia is 1-3/ 1000 preeclamptic pts - may occur despite magnesium sulfate therapy - in most cases seizures are self limited, lasting 1-2 minutes ***management - ensure that the airway is clear, prevent injury, and aspiration of gastric contents - usually accompanied by a prolonged fetal heart rate deceleration that resolves after the seizure has ended - if possible, a 10-20 minute period of in utero resuscitation should be permitted prior to delivery - does not necessarily constitute an indication for C section - however, if vaginal birth is not possible w/in a reasonable period of time, C section is performed in most cases

nomenclature

- preterm: one born prior to 37 wks -term: beyond 37 wks - postterm: after 42 wks - abortion: occurs before 20 wks - after 20 wks it is considered a preterm or premature delivery

male sexual disorders key points

- prevalence of erectile dysfunction increases with age - vascular risk factors increase the risk of erectile dysfunction - behavioral techniques for premature ejaculation are important for sustained success w/o pharmacologic tx - phosphodiesterase 5 (PDE5) inhibitors are the first line tx for ED - premature ejaculation is defined as a less than 1 minute intravaginal ejaculatory latency; SSRIs can delay ejaculation and can be used to treat premature ejaculation

amenorrhea

- primary or secondary - primary: caused by obstruction of outflow tract, androgen insensitivity, gonadal dysgenesis, hyperprolactinemia, and dysfunction of the hypothalamus, pituitary or thyroid - pregnancy is the most common cause of secondary amenorrhea - secondary is more common than primary - etiology of primary will fall into congenital or anatomic abnormalities - congenital etiologies include: chromosomal abnormalities, prenatal adrenal hyperplasia, female virilization syndromes - anatomic etiology are usually discovered at menarche, imperforate hymen being a common etiology - amenorrhea causes: hyperprolactinemia, prolactin secreting tumor, centrally acting meds including dopamine antagonists, pituitary disease, non prolactin secreting pituitary tumor, generalized pituitary insufficiency, hypothalamic amenorrhea, nutrition/ exercise disorders

syphilis tx

- primary/ secondary/ early latent tx is **2.4 million units IM of penicillin G benzathine - **jarisch herxheimer reaction: febrile reaction that occurs w/in first 24 hrs of tx - PCN allergic: doxycycline - pregnant and PCN allergic: desensitization with allergist - tertiary and late latent tx: same as primary but once a wk for 3 wks or IV PCN for 2 wks

contraception overview

- provides **control over pregnancy timing and prevention of unintended pregnancy - selecting a contraceptive method, individuals weigh factors such as efficacy, access, prevention of STIs, side effects, convenience, and noncontraceptive beliefs - contraceptive counseling provides education, dispels misinformation, facilitates selection of a method that will be successful for the individual, and encourages pt involvement in healthcare decisions and life goals - discussing contraception brings the doc and pt together to create a **tailored care plan that meets the pt's reproductive needs over a lifetime

vaginitis dx**

- pt hx - visual inspection of internal/ external genitalia - discharge appearance/ odor - collection of specimen - preparation/ exam of specimen slide - DNA probes - cultures - Fem examine test card - PIP activity test card

Sexual, Menstrual & Obstetric History key points

- questions about menarche, menstruation, menopause, reproductive, and sexual hx often give you an opportunity to explore the pt's concerns and attitude toward their body - individual men and women vary in their knowledge of, and comfort with, their own bodies - while some men and women may be quite open in disclosing their sexual, reproductive, and genital concerns, others will find such discussions embarrassing or socially inappropriate - it is essential that doctors maintain a sensitive and nonjudgemental approach

phyllodes tumor of breast

- rare - tumor cells grow in a leaf like pattern - most are benign, but malignancy is possible - tend to grow quickly, but rarely spread outside of the breast tissue - present with firm, palpable mass - most common b/n age 40-50

fetal HR sinusoidal patterns

- rare but particularly ominous - a/w a high rate of fetal morbidity and mortality - but can be seen after admin of narcotics to mother - smooth undulating sine wave pattern of 2-5 cycles/min and amplitudes of 5-15 beats/min with a notable absence of variability - occur with fetal anemia or severe hypoxia

hyperthyroidism during pregnancy

- rarely new dx during pregnancy -lab tests will confirm: elevated T4, FT4, FT3, and a suppressed or undetectable TSH; TSab titers will be elevated in a significant number of pts - Graves' disease is the etiology in most cases - Graves' caused by TSab which binds to TSH R: TSab may cross placenta and bind to fetal TSH R and cause fetal or neonatal hyperthyroidism, the placenta acts as a partial barrier to this - dx may be difficult as normal pregnant women experience many of the ssx of thyrotoxicosis - ssx: may resemble normal pregnancy, heat intolerance, warm and moist skin, tachycardia, systolic flow murmur... goiter, tachycardia, graves ophthalmopathy, weight loss or failure to gain weight despite good appetite

genito-pelvic pain/ penetration disorder

- refers to four commonly comorbid ssx: 1. difficulty having intercourse 2. genito-pelvic pain 3. fear of pain or vaginal pain 4. tension of the pelvic floor muscles - genito-pelvic pain is often idiopathic but may follow pelvic trauma, such as painful intercourse, childhood or adolescent sexual abuse, sexual assault, rough gynecologic exam, complicated episiotomy, vaginal infections, PID, or pelvic surgery

obstetrics esophagus and stomach changes

- reflux ssx affect 30-80% of pregnant women - gastric production of hydrochloric acid is variable and sometimes exaggerated but more commonly reduced -pregnancy is associated with greater production of gastrin, which increases stomach volume and acidity of gastric secretions - gastric production of mucus also may be increased - esophageal peristalsis is decreased - **the underlying predisposition to reflux in pregnancy is related to hormone mediated relaxation of the lower esophageal sphincter - the rate of gastric emptying of solid food is slowed in pregnancy, but the rate for liquids remains generally the same as the nonpregnant state

normal menstrual bleeding

- regular vaginal bleeding that occurs at intervals from 21-35 days - a normal menstrual cycle begins with the follicular phase before ovulation and luteal phase after ovulation

obstetrics renal function changes

- renal blood flow increases 50-85% above nonpregnant volume - GFR increases about 25% the second wk after conception, peaks at the end of the 1st trimester and remains high - even though GFR increases, the volume of urine excreted remains unchanged (increased reabsorption) - the creatinine clearance is increased in pregnancy, and normal creatinine levels are .46 as opposed to .67 nonpregnant

depression/ cognition

- risk of depression during perimenopause is higher than during the pre or post menopausal years - new onset depression as well as a relapse in women with a hx of depression - memory loss and difficulty concentrating during the menopausal transition and menopause: substantial biologic evidence supports the importance of estrogen in cognitive function

menopausal hormone therapy/ MHT tx principles

- routine mammograms and breast exams are recommended even with short term use - low estrogen oral contraceptive is an option for perimenopausal women who seek relief of menopausal ssx, who also desire contraception, and who in some instances need control of bleeding when it is heavy - tapering MHT has not been proven more effective than stopping tx abruptly

male sterilization/ vasectomy

- safer, more effective, cheaper - not immediately effective - need semen analysis - 98% azoospermic at 6 months

combined oral contraceptives initiation

- screening requirements: can be safely provided after a careful medical hx and BP measurement - documentation of BMI before starting OCs is suggested because obese women are at greater risk for venous thromboembolism with OC use - CBE/Pap/STI screen important but most groups agree not necessary before a first Rx for OCs -**quick start: start in office under supervision, backup X7 days - ** day 1 start: minimize chance of ovulation if start on Day 1 of cycle, balance with pt needs - **sunday start: backup X7 days, what is the rationale??? - **anytime start: is fine, use backup X7 dyas if middle of cycle - **switch from another method: start immediately

**glyburide for GDM

- second gen sulfonylurea: pregnancy category B - **does cross placenta in small amounts - compared with insulin in a randomized trial: similar outcomes but not as good as insulin... macrosomia, rates of C section, preeclampsia, fetal hypoglycemia - increased risk of macrosomia and hypoglycemia when compared to insulin - but recently only demonstrated a higher rate of neonatal hypoglycemia -start with 2.5 mg QD in morning, add 2.5 mg weekly until desired level reached - when 10 mg reached, change to BID dosing - if 10 BID not effective change to insulin - up to 85% will achieve control on glyburide alone what about first gen sulfonylureas.. NO, crosses the placenta - stimulates fetal pancreas and causes fetal hyperinsulinemia - potential teratogenicity

fetal concerns in managing seizure disorders

- seizures can cause fetal injury, spontaneous abortion, premature labor, and fetal bradycardia - all anti-epileptic drugs cross the placenta: levetiracetam and lamotrigine are category C, most others are category D, ativan for status epilepticus is cat D - **the goal of tx is monotherapy: tx with 2 or more antiseizure meds approximately doubles the risk for malformations - the risk of anomalies for infants exposed to anticonvulants is 2 fold greater than the general population - major malformations: orofacial clefts, NTD, congenital heart disease - minor malformations: craniofacial abnormalities, short neck, hypoplastic fingernails - must increase folic acid intake to 4 g daily (10x normal recommendation)

evaluation of male partner- dx tests

- semen analysis: key lab assessment, performed following a 2 to 4 day period of abstinence, semen volume and pH, microscopy, sperm concentration, count, motility, and morphology; debris and agglutination, leukocyte count, immature germ cells - if abnormal --> should repeat - if repeated semen analysis demonstrate a sperm concentration less than 15 million spermatozoa/mL--> serum testosterone, serum FSH, LH

sexual hx key points

- sexual behaviors determine risks for pregnancy, STD, and AIDS - sexual practices may be directly related to the pt's ssx and integral to both dx and tx - many pts have questions about sexuality that they would discuss more freely if asked about sexual health - sexual dysfunction may result from use of meds or from misinformation that can be readily addressed

evaluation of male partner- detailed hx

- sexual development hx, including testicular descent, pubertal development, loss of body hair, or decrease in shaving frequency - chronic severe systemic illness and hx of major head or pelvic trauma - infections such as mumps orchitis, sinopulmonary ssx, STI, GI tract infections, prostatitis - surgical procedures involving the inguinal and scrotal areas, such as vasectomy or orchiectomy - drugs and environmental exposure, including alcohol, tobacco, marijuana, opioids, radiation therapy, anabolic steroids, corticosteroids, cytotoxic chemotherapy, drugs that cause hyperprolactinemia, and exposure to toxic chemicals - sexual hx, including libido, frequency of intercourse, and previous fertility assessments of the man and his partner

sexual orientation spectrum

- sexual orientation may be a continuous spectrum from exclusive homosexuality to exclusive heterosexuality - some ppl who have sexually active with members of their own gender identify themselves as heterosexual; most doc overestimate the number of exclusively hetersexual pts in their practices - lesbians are less likely to obtain health maintenance services, mammography/PAP smears - any intact organ in a transgendered individual should be screened according current guidelines - compared with heterosexual men and women: gay women and men, and bisexual women are much more likely to have major depression and attempted suicide

human sexuality and define 1. gender 2. gender identity 3. sexual orientation

- sexuality is a fundamental aspect of human self concept and a complex biopsychosocial process - we as humans possess a gender identity and sexual orientation 1. correspond to our chromosomal or genital phenotypes 2. is a more comprehensive internal self perception 3. may be defined as attraction felt toward sexual partners of their own or the other gender, this is generally self defined and may change at different points in life

cell free DNA genetic prenatal testing

- short DNA fragments from chromosomes found in circulation - fetal and maternal DNA fragments are found in maternal circulation -dx testing - blood draw after 10 wks gestation - accurate for most trisomies - advantages: far more accurate than the quad screen, less invasive than amniocentesis with almost equal detection, can also eval for the Y chromosome - disadvantage: cost, many insurance companies are not covering full cost

when should prenatal care start

- should occur shortly after the woman discovers she might be pregnant and should be viewed as a continuation of preconception counseling: home pregnancy kits have a sensitivity and specificity of at least 95%, many can detect pregnancy by the fifth menstrual week - initiated in the first trimester, ideally by 10 wks of gestation: some prenatal screening and dx test can be performed at this gestational age, early initiation of care is also useful to establish early baseline measurements and provide early social service support and intervention when warranted - the percent of pregnant women who initiate prenatal care in the first trimester is one of the standard clinical performance measures used to assess the quality of maternal health care -in the past decade, about 75% of pregnant women in the US obtained prenatal care in the first trimester -the WHO estimated that 60% of women worldwide initiated prenatal care before 12 wks of gestation: less than half of women in developing regions received early antenatal care vs over 80% in developed regions, more than 4/5 women in the highest income group received early antenatal care versus 1/4 women in the lowest income groups

preconceptional care genetic screening

- sickle hemoglobinopathies: african americans - beta thalassemia - alpha thalassemia -tay sachs disease - canavan disease and familial dysautonomia - cystic fibrosis: caucasians - fragile X syndrome - duchenne's muscular dystrophy - down's syndrome and other chromosomal abnormalities

abnormal uterine bleeding

- some types of abnormal bleeding occurs in 10-30% of women of reproductive age - abnormal bleeding is a common reason for GYN referral and is an indication for up to 25% of all gynecologic surgery - includes abnormal menstrual bleeding and bleeding due to other causes such as pregnancy and systemic disease or cancer

PID ssx and dx

- ssx may be nonspecific, mild, severe - **pelvic pain is a main complaint, abnormal vaginal bleeding, dyspareunia, and vaginal discharge are also seen but nonspecific dx -any one or combo of the following pelvic exam findings, absent other illness in sexually active young women or women at risk for STDs, should be considered presumptive for PID: **cervical motion tenderness/ chandelier sign, **uterine tenderness, **adnexal tenderness - one or more of the following additional criteria may support the clinical dx of PID: **temp >101F, **abnormal cervical mucopurulent discharge or cervical friability, **large numbers of WBC on saline slide of vaginal fluid, **elevated CRP and/or ESR, **lab proven cervical infection with n. gonorrhoeae or C. trachomatis most specific criteria - **endometrial biopsy with histopathologic evidence of endometritis - **transvaginal US or MRI demonstrating thickened, fluid filled tube w/ or w/o free pelvic fluid or tuba-ovarian complex, or doppler suggesting tubal hyperemia - **laparoscopic findings consistent with PID - take home message: **clinical suspicion is mandatory as there is no single test or criteria that is 100% in all cases

prenatal/ first obstetric labs

- standard panel: every pregnant woman at the first prenatal visit, augmented by additional tests in women at risk for specific conditions, repetition of tests performed preconceptionally is unnecessary - Rh and ABO blood typing, abs: rhesus type and ab screen due to may be at risk for hemolytic disease of the fetus and newborn in offspring, rhogam is recommended for all nonsensitized Rh negative women at 28 wks gestation and w/in 72 hours after delivery of an Rh positive infant, written informed consent due to it being a blood product - CBC: H/H and MCV to check for anemia, if hemoglobin levels are <11 in 1st trimester then IDA, if MCV is less than 80 in the absence of IDA then increased risk for alpha or beta thalassemia - UA/ urine culture: screening for proteinuria, untreated asymptomatic bacteriuria are at high risk of developing pyelonephritis, modest risk for preterm birth - RPR, HIV, GC/CT, HBsAg, HCV if at risk - rubella - documentation of varicella immunity -PAP >21: frequency of cervical cancer screening is not influenced by pregnancy, but management of an abnormal test is different for pregnant women

preconception counseling- imaging

- standard transabdominal study of uterus with a full urinary bladder - transvaginal studies done with higher frequency probes to provide better resolution images and are done with an empty bladder: more commonly used for GYN eval - US for eval of pelvic mass or pelvic pain in female, and for eval of ovaries

general approach to pt with menopause

- start with assessment of menstrual cycle - hx of any menopausal ssx - all with ssx of vaginal dryness, dyspareunia, or sexual dysfunction should have pelvic exam to eval for vaginal atrophy

drugs associated w/ osteoporosis

- steroids - GnRH agonists - heparin - anticonvulsants - cytotoxic drugs - supra physiologic thyroxine dose - long acting progestins - PPI - lithium - SSRIs - barbiturates - chemotherapy

fetal HR late decelerations

- symmetric gradual fall in FHR beginning at or after the contraction peak, with a slow return to baseline only after the contraction has passed - **a/w fetal hypoxia, uteroplacental insufficiency - provoked by uterine contractions - postdate gestation, preeclampsia, chronic HTN, and DM are among the many causes

obstetrics blood pressure changes

- systemic arterial pressure declines slightly during pregnancy, reaching a nadir at 24-28 wks - pulse pressure widens because of the fall is greater for diastolic than for systolic pressures, systolic and diastolic pressure and MAP increase to prepregnancy levels by about 36 wks - venous pressure progressively increases in the lower extremities, particularly when the pt is supine, sitting, or standing - the rise in venous pressure, which can cause **edema and varicosities, results from compression of the inferior vena cava by the gravid uterus and possibly from the pressure of the fetal presenting part on the common iliac veins

osteoporosis background

- systemic skeletal disease characterized by architectural deterioration of bone - increased risk for fractures - largely preventable complication of menopause

male reproductive physiology

- testosterone and inhibin are produced by the testes - testosterone has a negative feedback on the hypothalamus and LH production, while inhibin has a negative feedback on FSH production

obstetrics RBC changes

- the RBC mass expands by about 33% or by 450 mL of erythrocytes for the average pregnant woman - the increase is greater with iron supplementation - **the greater increase in plasma volume accounts for the anemia of pregnancy - ***anemia of pregnancy is physiologic: iron supplementation is very important part of prenatal vitamin

prenatal/ first obstetric nutritional counseling

- the appropriate weight gain range based on prepregnancy BMI during the 2nd and 3rd trimesters of pregnancy --underweight: BMI less than 19, weight gain of 28-40 lbs --normal: BMI 19-25, weight gain of 25-35 --overweight: BMI 25-29.5, weight gain of 15-25 -- obese: BMI >30, weight gain of 11-20 - inadequate weight gain has been associated with low birth weight, avoid fasting or skipping meals - emphasize the right amount of nutrition over the right amount of weight gain: normal pregnancy requires an increase in daily caloric intake of 300kcal

preconceptional care- nutrition

- the average woman weighing 58kg (127lbs) has a normal dietary intake of 2300kcal/d - an additional 300kcal/d is needed during pregnancy - an additional 500kcal/d is needed during breastfeeding

obstetrics gallbladder changes

- the emptying of the gallbladder is slowed in pregnancy and often incomplete - bile stasis of pregnancy increases the risk for gallstone formation, although the chemical composition of bile is not appreciably altered

prenatal care

- the first prenatal visit is one of the most important, particularly if the woman had not had preconception care - hx, PE, and lab studies can help ID pregnant women at increased risk of medical complications, pregnancy complications, or fetal abnormalities - early ID of these women is an opportunity to discuss these issues and their management with teh pt and offer interventions to prevent or minimize the risk of an adverse outcome

obstetrics CV anatomic changes

- the heart shifts laterally, with a left upward displacement - the heart increases about 12% in size: proliferative growth, intracardiac volume increases by 80 mL, vascular changes include hypertrophy of smooth mm and reduction in collagen content

obstetrics metabolism changes

- the most obvious physical changes are weight gain and altered body shape - weight gain results not only from the uterus and its contents, but also from increased breast tissue, blood volume, and water volume in the form of extravascular and extracellular fluid - average weight gain is 27.5 lbs, if starting with a low BMI then closer to 40 lbs, if starting with a high BMI then closer to 20 lbs - metabolism of carbs and insulin during pregnancy changes, pregnancy is associated with insulin resistance (human placental lactogen/ hPI) which can lead to hyperglycemia (gestational DM) in susceptible women

define high risk pregnancy and the factors that may lead to high risk

- the mother, fetus, or newborn is at increased risk of morbidity or mortality before, during, or after deliver factors - maternal health and hx: prior OB hx, current medical problems - paternal hx - fetal disease

prevention of preeclampsia

- the observed alteration in the ratio of vasoconstrive and vasodilatory prostaglandins in preeclampsia led investigators to study the effectiveness of prostaglandin synthesis inhibitors in preventing the disorder - several small trials of low dose aspirin reported significant reductions in the incidence of preeclampsia in high risk population - a conflicting trial compared low dose aspirin to placebo and their was not a reduction in preeclampsia - **reviewing all the conflicting evidence, investigators for the cochrane collaboration concluded there may be a small to moderate benefit of low dose aspirin in preventing preeclampsia, because the risks of the regimen are few, some docs may reasonably choose to use it - Ca is essential in the synthesis of NO, a potent vasodilator believed to contribute to the maintenance of reduced vascular tone in pregnancy, although several small studies suggested a possible benefit of Ca supplementation in preventing preeclampsia

indications of probable embryonic demise

- the presence of a **gestational sac of 8 mm w/o a demonstratable yolk sac - **a gestational sac of 16mm w/o a demonstratable embryo - **the absence of a fetal cardiac motion in an embryo with a crown rump length of greater than 5 mm - if any doubt about these measurement: best to repeat the eval in 1 wk before terminating the pregnancy

fetal HR accelerations

- transitory increase in FHR associated with fetal movement, scalp or acoustic stimulation, and uterine contractions - considered reassuring and are associated with fetal well being - presence of two or more accelerations of 15 beats/min above baseline for at least 15 seconds

infertility

- unique medical condition because it involves a couple, rather than a single individual - defined as inability of a couple to conceive after 12 months of regular intercourse w/o the use of contraception in women less than 35 yo, and after six months in women older than 35 - subfertility: a decrease, but not absence, of fertility potential - sterility: complete inability to achieve fertility - fecundity: probability of achieving a live birth in one menstrual cycle etiology - male factor: hypogonadism, post testicular defects, seminiferous tubule dysfunction - ovulatory dysfunction - tubal damage - endometriosis - coital problems - cervical factors - unexplained eval - may have multiple factors contributing: a complete initial dx eval including complete H&P, this will detect the most common causes of infertility - recognition, eval, and tx of infertility are stressful for most couples: the doc should not ignore the couple's emotional state, which may include depression, anger, anxiety, and marital discord

progestin only pills (the mini pill)

- used in breast feeding - can be used in women who cannot receive estrogen: smokers over 35 YO, VTE hx, CAD, CVA - taken daily: no hormone free days - must be taken same time every day - heavy, irregular bleeding: most common reason for discontinuation

combined oral contraceptives uses

- useful in tx of women with hyperandrogenism most often due to PCOS - other uses: dysmenorrhea, menorrhagia, other menstrual cycle disorders such as hypothalamic amenorrhea, and as hormone replacement in women with primary hypogonadism, premenstrual dysphoric disorder

fundal height

- usually correlates with gestational age - 12 wks: palpated out of the pelvis - 20 wks: umbilicus - 36 wks: maximum growth in height mcdonald's rule - the wk of gestation and the fundal height are in the ratio of 1:1 from about 18-36 wks - not helpful in obese pt

side effects of hormone replacement therapy

- uterine bleeding - breast tenderness - nausea - abd bloating - fluid retention in arms and legs - hair loss - h/a - dizziness

benign pelvic pathology causing abnormal bleeding in reproductive age women

- uterine leiomyomas (fibroids): noncancerous growth in uterus which often appear during childbearing years - endometrial polyps: growth attached to the inner wall of the uterus and extends into the uterine cavity, usually noncancerous but some may be cancerous or become cancerous - adenomyosis: endometrial tissue w/in the myometrium of the uterus

obstetrics peripheral vascular resistance changes

- vascular resistance decreases in the first trimester, reaching a nadir of about 34% below nonpregnancy levels by 14-20 wks with a slight increase toward term - the hormonal changes of pregnancy likely trigger this fall in vascular resistance by enhancing local vasodilators such as NO, prostacyclin, and adenosine - delivery is associated with nearly a 40% fall in PVR, although MAP is generally maintained because of the associated rise in CO

menopause ssx

- vasomotor instability: hot flushes (hallmark ssx), sleep interruptions - GU ssx: vaginal dryness, dyspareunia, urethral irritation - psychological ssx: depression, mood swings, insomnia, libido changes, concentration difficulties - other: breast pain, menstrual migraines

intimate partner violence/ IPV survivor safety

- vast majority of pts are not in imminent danger and are not planning to leave their relationship; it should not be overlooked that IPV can result in death: assess for safety and making a safety plan can decrease the risk of mortal harm - ask the pt how afraid they are and what they think are their immediate and future safety needs - pts should be offered referral to talk to about options and safety

intimate partner violence/ IPV epidemiology- world wide

- via survey by world health organization of over 24,000 women in 10 countries - lifetime prevalence of physical or sexual IPV ranged from 15-75% - in almost all site, the risk of partner related physical or sexual violence far exceeded the risk of other violence - physical violence only was the most common pattern of IPV -globally, as many as 38% of murders of women are committed by male intimate partners

breast abscess

- warm, erythematous, tender, indurated mass - staph aureus most common - rarely occur in a non lactating breast - consider inflammatory carcinoma if found in non lactating breast

osteoporosis protective actions

- weight bearing exercise: low impact or step aerobic, walking, tennis - impact loading exercise: weight lifting - exercise stimulates osteoblastic activity -**daily elemental Ca: 30-50 yo 100mg, >50 yo with estrogen 1200mg, >50 w/o estrogen 1500mg - **vit D 800-100/day: moderate sunlight, cannot absorbed Ca w/o vit D - **lifestyle modification: balance exercise, home safety, nonskid rugs, ample lighting, handrails in showers and along stairs

sexual hx- prevention of pregnancy

- what are you doing to prevent pregnancy

sexual hx- protection from STIs

- what do you do to protect yourself from STIs and HIV

menopausal dx

- women >45 -> with irregular menstrual cycles and menopausal ssx such as hot flashes, mood changes, or sleep disturbances -> no further dx eval -> highly likely to be in menopausal transition - serum FSH is often measured, but not necessary to make dx, if normal it may be misleading - lab indicators: FSH > 40, estradiol <20 - always consider possibility of pregnancy -> get hcg in sexually active women who are not using reliable contraception - endocrine testing: prolactin, TSH if there are any suggestive features of hyperprolactinemia or thyroid disease - over 45 with with irregular cycle and no other ssx suggestive of menopausal transition: asymptomatic women with irregular period, a serum FSH >15-25 would be reassuring that this is simple the menopausal transition and nothing else

contraceptive efficacy

- women are encouraged to select one of the most effective contraceptive options - in practice, contraceptive methods can be divided into three tiers based upon their theoretical and actual effectiveness: most effective, effective, least effective

MRI screening

- women with known BRCA mutation - first degree relative w/ a BRCA mutation - prior mantle radiation

tertiary syphilis

-** may present yrs to decades after initial infection and may manifest in a variety of presentations - **neurosyphilis: h/a, meningitis, mental status changes - CV syphilis: **aortitis of ascending thoracic aorta with aortic valve regurgitation - **gummatous syphilis: uncommon but gummas have been noted in some pt with HIV as well - otosyphilis - **general paresis: dementia, forgetfullness, psychiatric disturbances, personality changes - **argyll roberston pupils: small pupil with no response to light but accommodation is normal - **tabes dorsalis: argyll robertson pupil, with sensory ataxia and lancinating pains, longest latency of neurosyphilis

preconceptional care- supplements

-***folic acid: most important, prevents NTD, **.4 mg daily, should start at least 3 mon prior to conception, if hx of prior NTD then **4mg daily -**iron supplementation: 30mg of elemental iron/day recommended by CDC, start at the first prenatal care visit, very difficult to absorb, take on empty stomach - others: vit D 10mcg daily for vegans, vit B12 2mcg daily for vegans, Ca 1300mg daily for women <19yo and 10000mg daily for women 19-50yo - avoid fish: tilefish, swordfish, shark, king mackerel, marlin, orange roughy, tuna (bigeye, ahi) - fish oil: omega 3 FA, family of long chain polyunsaturated FA that are essential nutrients for health and development, not synthesized by human body so need diet or supplement --EPA (fish oil): supports the heart, immune system, and inflammatory response --DHA (fish oil): supports the brain, eyes, and CNS which is why it is uniquely important for pregnant and lactating women

common complaints in pregnancy

-**N/V - hemorrhoids - heartburn - ptyalism: increased salivation and difficulty swallowing saliva - pica: eating weird stuff - frequency of urination - STD: syphilis, gonorrhea, chlamydia, HSV, HIV, trichomonas - other infections: candidiasis, bacterial vaginitis - varicose veins - joint pain, back pain, pelvic pressure - leg cramps - lower extremity swelling - discomfort in the hands: increased carpal tunnel syndrome - breast soreness

tuba-ovarian abscess/ TOA presentation and dx

-**PID ssx: acute lower abd pain, fever, chills, and vaginal discharge - up to 40% will not have fever and some will have no discharge - **ruptured/leaking abscess: presents with acute abdomen and signs of sepsis - **exam: appear acutely ill, moderate to severe tender abd, possible adnexal mass of pelvic w/ tenderness - **elevated WBC in most cases, elevated inflammatory markers (ESR/CRP) - **US first line study, CT if GI path considered - **surgical eval: acute abd, signs of sepsis/ shock, post menopausal to r/o malignancy - **dx: hx, clinical suspicion, clinical findings suggestive and imaging suggestive, direct visualization is only way for definitive dx in many cases

genetic screening**

-**all should receive appropriate pretest genetic counseling to make an informed choice: should be offered to couples who did not receive it before conception - pts undergoing any screening test should understand the difference b/n a screening and dx tests - need accurate dating of pregnancy - need to understand the limits of tests: pretest probability, positive and negative predictive values

calculation of estimated date of delivery

-**nagele's rule: subtract 3 mon from the LMP and add 7 days; if pts first day of her LMP was september 16th 2017, her EDC would be june 23rd 2018 - **the most important part of the first prenatal visit, never changes once established - compare the first day of LMP with the first US measurement EDD, if the US EDD is not consistent with LMP, change the EDD to the one by US (hadlock's criteria)

hyperthyroidism tx during pregnancy

-**propylthiouracil/PTU: shorter acting, initial dose 200-400mg daily - **methimazole: initial dose 20-40 mg daily, less dosing improves compliance, initial dose is gradually reduced as improvements occurs -women who have remained euthyroid for 4 wks or longer can stop taking the med altogether by 32-34 wks under close surveillance - **beta blockers: can be used for ssx relief - **monitor TSH and free T4 (keep T4 at high normal range) - **fetal well being: US for fetal growth every 4 wks

fetal HR early decelerations

-**vagal response to fetal head compression resulting in a slowing of FHR - smooth, uniform shape that is a mirror image of the corresponding contraction - reassuring and are associated with a good outcome

phases and duration of menstrual cycle

-1st day of menses represents the first day of the cycle (day 1) - the cycle is then divided into 2 phases --**follicular phase: begins with the onset of menses and ends on the day before the LH surge --**luteal phase: begins on the day of the LH surge and ends at the onset of menses - average adult menstrual cycle last 28-35 days, with approximately 14-21 days in the follicular phase and 14 days in the luteal phase

eval and tx for menorrhagia

-CBC, pregnancy test, coagulation profile, vWF disease screening - tx with hormonal contraception for cycle control

characteristics of some causes of secondary dysmenorrhea

-Endometriosis: Pain extends to premenstrual or postmenstrual phase or may be continuous; may also have deep dyspareunia, premenstrual spotting, a fixed retroverted uterus, and tender pelvic nodules (especially on the uterosacral ligaments); onset is usually in the 20s and 30s but may start in the teens. -Pelvic Inflammation: Initially pain may be menstrual, but often with each cycle it extends into the premenstrual phase; may have intermenstrual bleeding, dyspareunia, and pelvic tenderness. -Adenomyosis, Fibroid Tumors: Uterus is generally symmetrically enlarged and may be mildly tender; dysmenorrhea is associated with a dull pelvic dragging sensation; hypermenorrhea and dyspareunia may be present. -Ovarian Cysts (Especially Endometriosis and Luteal Cysts): Should be clinically evident. -Pelvic Congestion: A dull, ill-defined pelvic ache, usually worse premenstrually, relieved by menses; not all investigators agree that this is a cause of chronic pelvic pain.

Primary Dysmenorrhea

-Features of Primary Dysmenorrhea: presence of recurrent, crampy, lower abdomen pain occurring during menses and in the absence of any disorder. -Initial Onset: 90% experience symptoms within 2 years of menarche (i.e., when ovulation begins). -Duration and Type of Pain: Dysmenorrhea begins a few hours before or just after the onset of menstruation and usually lasts 48-72 hours. Pain is described as cramp-like and is usually strongest over the lower abdomen, but may radiate to the back or inner thighs. -Associated Symptoms • Nausea and vomiting • Fatigue • Diarrhea • Lower backache • Headache -Pelvic Examination • Normal findings

PLISSIT model for approaching sexual problems

-Permission: for doc to discuss sex with pt, for the pt to discuss concerns now or in the future, to continue sexual behaviors not potentially harmful - Limited info: clarify misinformation, dispel myths, provide factual info in a limited manner - Specific suggestions: provide specific suggestions directly related to the particular problem - Intensive tx: provide highly individualized therapy for more complex issues

maternal thyroid function during normal pregnancy

-T4 and T3 increase because their carrier, thyroid binding globulin increases secondary to increased levels of E2 - TSH decreases - TSH is lowest and FT4 is highest when HCG is at its peak - thyroid increases in size by about 18% and even more so in iodine deficiency

fetal HR variable decelerations

-acute fall in FHR with a rapid down slope and a variable recovery - variable shapes, at times described as being V, U, or W - variable relationship with contractions - most commonly encountered pattern - **almost always caused by umbilical cord decompression - segments of FHR accelerations just before and after the variable decelerations (shoulders) indicate a healthy response

hyperemesis gravidarum tx

-admit to hospital - IV hydration - promethazine (phenergan) may be added to IV fluids - ondansetron (zofran) - metoclopramide (reglan) 10 mg PO TID: can also use outpt, rare cause of tardive dyskinesia - methylprednisolone dose pack, or taper - rarely total parenteral nutrition -**ptyalism: spitting associated with H.G. may respond to changing to chlorpromazine 10-50 mg PO - there is a strong association of psychological factors that are seen commonly in H.G.

obstetrics pulmonary anatomic changes

-capillary dilation leads to engorgement of the nasopharynx, larynx, trachea, and bronchi - as the uterus enlarges, the diaphragm is elevated by as much as 4cm - the rib cage is displaced upward, increasing the angle of the ribs with the spine - these changes increase the lower thoracic diameter by about 2 cm and the thoracic circumference by up to 6 cm

mercury toxicity during pregnancy

-contaminant found in fish *** - affects brain development and nervous system - prevents myelin sheath formation - irreversibly inhibit activities of selenoenzymes such as thioredoxin reductase which restores vit C and E back into their reduced form enabling them to counteract oxidative damage w/in body cells FDA guidelines - no more than 12 oz of low mercury fish should be consumed weekly - highest mercury fish should be avoided - high mercury fish should be kept to only three 6oz servings per mon

follicular phase

-day 1-5: ovary is the least hormonally active= low serum estradiol and progesterone concentration, disintegration and sloughing of functionalis layer, prostaglandin F2 alpha causes contractions and vasoconstriction, prostaglandin E2 causes vasodilation and mm relaxation - day 5-14: estrogen produced by developing follicles stimulated by FSH, cellular proliferation and increase in convolutedness of spiral arteries, estrogen positive feedback causes FSH and LH surge and ovulation

alcohol during pregnancy***

-fetal risks are only with chronic alcoholics - **the precise levels of alcohol consumption during pregnancy that causes adverse effects has not been established -**there is no exact dose response relationship b/n the amount of alcohol consumed during the prenatal period and the extent of damage caused by alcohol in the infant **fetal alcohol syndrome -follows maternal ethanol ingestions has been described - incidence varying from 1 in 1500 to 1 in 600 live births - rate of reported cases ID among newborns in the US during 1979-1992 approx increased 4 fold - major features: growth retardation, characteristic facial dysmorphology (microcephaly, microphthalmia), CNS deficiencies

initial OB visit PE

-general exam - pelvic exam: bony pelvis (pelvic inlet: diagonal conjugate, pelvic outlet), cervical dilation and length (normally 3-4 cm)

evaluation of male partner- PE

-general exam to determine overall health, obesity, and overt ssx of endocrinopathies that are uncommon cause of male infertility (thyroid dysfunction or cushing's syndrome) - look for findings suggestive of androgen deficiency depending on age of onset: in early gestation presents as atypical genitalia, in late gestation as micropenis, in childhood as delayed pubertal development, in adulthood as decreased sexual function, infertility, and eventually loss of secondary sex characteristics - external genitalia normal location of the urethral meatus, testicular size should be estimated, look for incomplete sexual development, presence of varicocele

intercourse during pregnancy

-generally considered safe, with no fetal risks when its a good idea - at term, orgasm may help in initiating contractions - the prostaglandin in semen can also increase contractions when its a bad idea - premature labor - hx of premature delivery - placenta previa - any abnormal bleeding

obstetrics platelet changes

-gestational thrombocytopenia occurs in about 6% of pregnancies - platelet counts fall below 150000

breast feeding

-has been shown to significantly reduce morbidity and improve cognitive development during infancy and childhood - initiate discussion at first visit - ID and address any barriers - referral to a childbirth preparation class or a lactation consultant may provide additional encouragement to initiate and support breastfeeding

classification of maturity***

-immature infant: weighs 500-1000g and has completed 20-28 wks gestation - premature infant: weighs 1000-2500g and duration of 28-37 wks gestation - low birthweight infant: live born infant weight 2500g or less at birth - undergrown or small for gestational age infant: significantly undersized for the period of gestation - mature infant: live born infant completing 37 wks gestation and usually weighs more than 2500g - postmature infant: completed 42 wks or more gestation

obstetrics bladder changes

-increased frequency due to small area for bladder - ironically, because of increased vascularity and decreased tone, the capacity increases up to 1500mL

evaluation for female sexual arousal disorder

-lab testing: CBC, BG, thyroid function, lipid profile, LFTs, prolactin, estrogen, DHEA, testosterone - imaging may include ultrasound for structure

medical management of asthma**

-mild, intermittent asthma: 2-4 puffs of short acting beta2 agonist as needed, for acute exacerbation use symptomatic corticosteroids - mild, persistent asthma: low dose inhaled corticosteroid - moderate, persistent asthma: combo of inhaled corticosteroid and long acting beta2 agonist (salmeterol, formoterol) - severe, persistent asthma: high dose inhaled corticosteroid, long acting beta2 agonist, and if needed systemic corticosteroid

monosomy 21-22

-moderate mental retardation, antimongoloid slant of eyes, flared nostrils, small mouth, low set eyes, spade hands

intrauterine contraception (IUD)

-most commonly used method of long acting reversible contraception due to its high efficacy and safety, ease of use, and low cost - provides a nonsurgical option for pregnancy prevention that is as effective as surgical sterilization - made of plastic and release either copper or a progestin to enhance the contraceptive action of device - pt satisfaction and continuation rates are high - insert any time in cycle as long as pregnancy is ruled out -candidates: good choice for those who desire one of the most effective methods, desire long term yet reversible action, want or need to avoid estrogen exposure or hormone exposure - contraindications: severe distortion of uterine cavity, active pelvic infection, known or suspected pregnancy, wilson's disease or copper allergy, unexplained abnormal uterine bleeding, breast cancer, liver disease

define menopause

-no menstrual cycle for 12 months - surgical, medical, or physiological - usually determined in retrospect - **definition is not based on symptomalogy - average age in US is 51 yo - anytime after 40 is considered normal - before 40 is considered premature ovarian failure

preconceptional care immunization

-offer to women before pregnancy - rubella - varicella - hep B - tetanus, diptheria, pertussis: CDC recently recommended to give during pregnancy after 20 wks no matter prior hx - pneumovax: splenectomy or functional asplenia from sickle cell disease - cannot give MMR booster during pregnancy due to being live attenuated vaccine - flu (nasal) and varicella are contraindicated

preconceptional care- DM

-optimize HbA1C - avoid ketonuria - eval renal function, proteinuria - opthamology exam -rule out other medical conditions: check TSH, EKG - meds: insulin and glyburide is shown to be safe, metformin likely safe, other oral hypoglycemics cross the placenta

preconceptional care- asthma

-optimize peak flow

employment during pregnancy

-pt can work until their due date, unless they are dangerous/ severely active - have to gently explain this to pt - it is unethical to give a pt medical leave when you cannot medically justify it when pt should not work - elevated BP/ preeclampsia -premature labor, advanced cervical dilatation - environmental/ work hazards - others - in general, i will limit their work hrs or give restrictions for lifting or request their employer find a different job description while pregnant

gynecomastia

-refers to a benign enlargement of the male breast resulting from a proliferation of breast glandular tissues - can be u/l, b/l or asymmetric - any palpable breast tissue is abnormal except in transient **gynecomastia of newborns, **pubertal gynecomastia, and **gynecomastia of older men - can be iatrogenic due to medication - breast cancer in men is uncommon but does occur, prognosis is much worse than it is for women - tx based on removal of offending drug or correction of underlying condition, anti-estrogen therapy may be considered, surgical correction may be considered for alleviation of ssx

peripheral precocious puberty

-results from tumors generating sex steroids, exogenous agents with properties of sex steroids

obstetrics oral cavity changes

-salivation appears to increase although this may be caused in part by swallowing difficulty associated with nausea - pregnancy does not predispose to tooth decay or to mobilization of bone Ca - the gums may become hypertrophic and hyperemic, often they are so spongy and friable that they bleed easily

other gynecologic hx

-types of contraceptives, past and current - cervical cytology (PAP test) and mammogram hx: date and result of last test, dx and follow up of abnormal result - prior STIs or PID: dx, frequency, and tx - hx of other gynecologic problems, such as ovarian cysts, uterine fibroids, infertility, endometriosis, PCOS... mode of dx and tx - hx of gynecologic procedures: date, indication, complication - ssx of pelvic organ prolapse or urinary/ anal incontinence - screening for intimate partner violence

******define these HTN disorders in pregnancy 1. preeclampsia 2. eclampsia 3. superimposed preeclampsia-eclampsia 4. gestational HTN 5. transient HTN of pregnancy

1. **HTN that occurs after 20 wks of gestation in a woman with previously normal BP, systolic >140 or diastolic >90, **proteinuria (defined as urinary excretion of >.3 g protein in a 24 hr urine, or **urinary protein: creatinine ratio of .3 mg/dL or higher), **edema facial and hand but this is no longer is a dx criterion 2. new onset grand mal **seizures in women with preeclampsia that cannot be attributed to other causes 3. preeclampsia or eclampsia that occurs in a woman with a **pre-existing chronic HTN 4. HTN detected for the first time after midpregnancy, distinguished from preeclampsia by the **absence of significant proteinuria 5. gestational HTN that resolves by 12 wks postpartum, if proteinuria develops in a pt with gestational HTN the dx is preeclampsia, if gestational HTN does not resolve by 12 wks postpartum the dx is chronic HTN

intimate partner violence/ IPV initial approach to the pt: four guiding principles for intervention

1. **survivor safety: being always aware that the primary concern is to maximize safety and not increase risk for further harm 2. **survivor empowerment: facilitating the pt's ability to make their own choices 3. **perpetrator accountability: framing the violence occurring because of the perpetrator's behavior and not the survivor's 4. ** advocacy for social change: collaboration and advocacy beyond the healthcare setting

define 1. menarche 2. menopause 3. postmenopausal bleeding 4. amenorrhea 5. dysmenorrhea 6. premenstrual syndrome 7. abnormal uterine bleeding

1. age at onset of menses 2. absence of menses for 12 consecutive months, **usually occur b/n 45-55 yo 3. bleeding occurring 6 months or more after cessation of menses 4. absence of menses 5. pain with menses, often with bearing down, aching, or cramping sensation in the lower abd or pelvis 6. a cluster of emotional, behavioral, and physical ssx occurring 5 days before menses for 3 consecutive cycles 7. bleeding b/n menses, including infrequent, excessive, or postmenopausal bleeding

genetic screening 2 categories

1. assessment of maternal serum levels of specific biochemical markers associated with trisomy 21 and 18, with or w/o assessment of specific US markers - nuchal translucency: ideal around 12 wks gestation, thickness <3 mm is normal, >3 mm suggestive of chromosomal abnormality or NTD 2. assessment of cell free DNA in the maternal circulation to screen for trisomy 21, 18, 13, and sex chromosome aneuplodies - circulating cfDNA is derived from both the mother and the fetus, most fetal DNA is derived from the placenta

define 1. transgendered 2. transsexual 3. cross dressers 4. intersex 5. gender dysphoria

1. individuals transiently or persistently identify with a gender different than their natal gender 2. individuals is one who seek to take on the social role of the other gender, either full or part time; often with the assistance of hormone therapy, surgery, or both 3. are persons who at times may dress as the other gender to be publicly perceived as such or for sexual pleasure 4. is a different medical concept and refers to persons born with ambiguous genitalia or for whom phenotypic and chromosomal sex do not match 5. is clinically distressing incongruence b/n one's natal gender and one's expressed or experienced gender

trichomoniasis vaginitis** 1. ssx 2. discharge 3. clinical findings 4. pH 5. KOH whiff test 6. NaCl wet mount 7. KOH wet mount

1. itch, discharge, 50% asymptomatic 2. frothy, gray, or yellow green, malodorous 3. cervical petechiae, strawberry cervix 4. >4.5 5. often positive 6. motile flagellated protozoa, many WBCs 7. -

candidiasis vaginitis** 1. ssx 2. discharge 3. clinical findings 4. pH 5. KOH whiff test 6. NaCl wet mount 7. KOH wet mount

1. itch, discomfort, dysuria, thick discharge 2. thick, clumpy, white, cottage cheese 3. inflammation and erythema 4. <4.5 5. negative 6. few WBCs 7. pseudohyphae or spore if non-albicans spp

genetic screening tests results for 1. trisomy 21/ down syndrome 2. trisomy 18/ edward's syndrome 3. trisomy 13/ pateau's syndrome 4. neural tube defect

1. low AFP and PAPP-A, normal uE3, high hCG and inhibin A 2. low AFP and PAPP-A, very low uE3 and hCG, normal inhibin A 3. normal everything 4. very high AFP

male factor 1. oligospermia 2. asthenospermia 3. teratospermia 4. azospermia

1. low concentration 2. low motility 3. poor morphology 4. no sperm: previous vasectomy (obstructive), congenital b/l absence of the vas deferens associated with cystic fibrosis, germ cell arrest from Y chromosome microdeletions

bacterial vaginosis vaginitis** 1. ssx 2. discharge 3. clinical findings 4. pH 5. KOH whiff test 6. NaCl wet mount 7. KOH wet mount

1. odor, discharge, itch 2. homogenous, adherent, thin, milky white, malodorous, foul fishy 3. - 4. >4.5 5. positive 6. clue cells, no/few WBCs 7. -

evaluation of male partner- endocrine testing

1. primary (hypergonadotrophic) hypogonadism - low testosterone, and high FSH and LH: affect both spermatogenesis and leydig cell function... if positive then have karyotype performed - normal testosterone and LH, and high FSH: seminiferous tubule damage w/o leydig cell dysfunction 2. secondary (hypogonadotrophic) hypogonadism - low testosterone, but FSH and LH are not elevated - get prolactin levels to rule out hyperprolactinemia 3. normal testosterone, LH and FSH: further eval depends on findings on semen analysis 4. normal endocrine testing and azoospermia - should be eval for ejaculatory duct obstruction - dx by a scrotal or transrectal US showing dilated seminal vesicles 5. low sperm count and very low LH in muscular man --> suspect androgen abuse

breast cancer 1. what is critical for detection 2. 1st step in eval of breast mass 3. fold standard for dx

1. thorough hx and PE 2. mammogram 3. tissue biopsy

preeclampsia management

37 wks - deliver less than 37 wks (preterm) - admit to hospital initially - monitor BP and labs - US for EFW (estimated fetal weight) and presentation and BPP - continuous fetal monitoring - anti-HTN med and seizure prophylaxis - steroids are needed <34 wks to accelerate fetal lung maturity - if stable continue to monitor inpt - outpt management possible IF: BPs are stable, labs are normal, ssx resolve off magnesium sulfate, pt has good transportation and live nearby, 2x wk office visits with BPPs and labs and 1x wk 24hr urine

preeclampsia with severe features management

>34 wks - deliver - may can wait until steroid window - magnesium sulfate IV for seizure prophylaxis and continue post partum 28-34 wks - admit to hospital with no outpt management - conservative tx is an option - monitor BP and labs - US for EFW and presentation and BPP - continuous fetal monitoring - antiHTN meds - magnesium sulfate IV for seizures prophylaxis - steroids are needed <34 wks to accelerate fetal lung maturity - some institutions will deliver at steroid window - mother needs to know of potential risks of prolonging the pregnancy - NICU consult

reading a fetal HR trace

C: contractions V: variability B: baseline.. most straight line across the tracing, normal 110-160 A: accelerations D: decelerations C: changes

ACOG classification system for abnormal bleeding in reproductive age women

PALM: structural causes - Polyp - Adenomyosis - Leiomyomas - Malignancy and hyperplasia COEIN: nonstructural causes - Coagulopathy - Ovulatory dysfunction - Endometrial - Iatrogenic - Not yet classified

syphilis presentation

PRIMARY STAGE: • Primary chancre: extremely infectious and teeming with spirochetes. • Painless, 1-2 cm diameter, non-exudative base, indurated ulcer with firm, raised borders. May present in multiples, especially in HIV positive patients. • Associated with lymphadenopathy as spirochete spreads. • Chancre present in most cases but may go unnoticed. • Heals spontaneously over several weeks. Many never know that they are infected. SECONDARY STAGE • Maculopapular rash, pink and symmetrical in appearance. • Rash will evolve to include palms and soles after a few weeks. Rash is not painful. Face is spared. • Resolves spontaneous over weeks. • Misdiagnosed as pityriasis rosea, erythema multiform, drug reaction rash, tine, measles, seborrheic dermatitis. • Will sometimes evolve into macular, papular, pustular, vesicular rash or combination of these. • May also have adenopathy, constitutional symptoms, moth-eaten alopecia, hepatitis, renal issues, and early neurologic issues. LATENT STAGE • Infected with T. pallidium confirmed via serologic testing but has NO symptoms

sexual hx 5 Ps

Partners Prevention of pregnancy Protection from STIs Practices Past hx of STIs

menopausal hormone therapy/ MHT contraindications

absolute - estrogen responsive breast cancer - endometrial cancer - undx abnormal vaginal bleeding - active thromboembolic disease - hx of malignant melanoma relative - previous thromboembolic disease - chronic liver disease - gallbladder disease - severe hypertriglyceridemia - endometriosis

shorthand for menstrual cycle hx

age at menarche x cycle length x number of days of bleeding mine: 17 x 25 x 5

mammogram screening

american cancer society - women b/n 40-44 should have the choice to start annual screening with mammograms - women 45-54 should have annual mammograms - women >55 should switch to mammograms every 2 yrs or they can continue annually - screening should continue as long as a woman is in good health and expected to live 10 yrs or longer US preventive service task force - women 50-74 should have mammograms biennially

pregnancy tests***

beta hCG - detectable at 1 day after implantation which occurs 8 days after midcycle LH peak - peaks at 9-10 wks - nonpregnant value <5 IU/mL - levels of 1800 should see a gestational sac - levels of 10000 should see positive fetal cardiac activity urine beta hCG - home pregnancy tests: question the accuracy of technique and interpretation, always repeat in office - usually if serum hCG is >25, it will show positive on urine test - many pt want serum test, if the urine is negative - hCG rises 66% every 48 hrs

(1/3) A 58-year-old G3P3003 Caucasian, postmenopausal woman comes to your office. She has been menopausal since age 50. She has a negative past medical and surgical history. She took hormone replacement for about 2 years but stopped due to concerns of an increased risk of cancer that she heard about from friends. Prior to the onset of menopause, she had a history of normal and regular menses. She has had annual GYN care with you, and has never been diagnosed with cervical dysplasia. Her last Pap smear with HPV was obtained last year and both were negative. She has recently become sexually active with a new partner and has noted some spotting with intercourse as well as intermittent spotting that she notices on wiping for the past 2 to 3 months associated with occasional mild lower abdominal cramping. She complains of a general feeling of vaginal dryness and does have pain and dryness with intercourse. She has no other complains what so ever. Her most likely diagnosis is: a.endometrial cancer b.cervical cancer c.urogenital atrophy d.bleeding dyscrasia e.uterine fibroids

c. urogenital atrophy

(3/3) You perform an examination testing for gonorrhea and chlamydial infection as well as perform an endometrial biopsy. In addition,you order a pelvic ultrasound. STD testing is negative. Her endometrial biopsy returns with inactive, atrophic endometrium, negative for hyperplasia or malignancy. Her transvaginal ultrasound reveals a normal appearing uterus with evidence of a 2 cm intracavitary lesion consistent with an endometrial polyp. Ovaries are normal; there is no free fluid present in the peritoneal cavity. The next most appropriate step in the management of this patient is: a.reassurance and follow up in 1 year b.reassurance and follow up ultrasound in 1 year c.outpatient hysteroscopy D&C with polypectomy d.treat the urogenital atrophy with systemic or vaginal estrogens and follow up in 3 months

c.outpatient hysteroscopy D&C with polypectomy

vaginitis most commonly characterized by and most common types

characterized by** - vaginal discharge - vulvar itching - irritation - odor most common types - bacterial vaginosis** - trichomoniasis** - vulvovaginal candidiasis** - mucopurulent cervicitis - HSV - atrophic vaginitis in post menopausal women - allergic reactions - vulvar vestibulitis - foreign bodies

human chorionic gonadotropin

composed of 2 subunits, alpha and beta -bhCG is more specific because alpha chains are similar to all glycoproteins - can be detected one day after implantation, made by syncitiotrophoblast cells, about 8 days after midcycle LH peak - concentration rise exponentially: ***about 66% every 48 hrs, peak at 9-10 wks - in molar pregnancy hCG is made at a must faster rate - half life is about 32-37 hrs, therefore it can still be detectable for 1-2 wks after miscarriage or ectopic pregnancy

A fourteen year old nulliparous female presents to the ER by ambulance because she passed out on the floor of her house and is covered with blood. She is now conscious. She has been bleeding off and on for the past 5 months since onset of menarche. Her BP is 98/48, pulse 106, respirations 16, temperature 96.2. Physical exam is unremarkable. Pelvic ultrasound is unremarkable. BhCG is negative, and hemogoblin is 7g/dL. You begin a low dose combination oral contraceptive taper. The next best step in management of this patient is: a.Endometrial biopsy b.Reassurance c.NSAIDs d.Coagulation profile

d.Coagulation profile

(2/3) On examination, she has normal appearing external female genitalia. She has a normal appearing rectum and a fecal immunoassay test is negative for blood. On speculum examination, she has pale, thin vaginal epithelium without lesions, blood or discharge. Her cervix is pale and stenotic but without lesions. A bimanual examination reveals a small, non-tender mid-position uterus, with no adnexal masses.The most appropriate testing includes: a.endometrial biopsy b.transvaginal ultrasound c.STI testing (gonorrhea and chlamydia) d.all of the above e.none of the above

d.all of the above

trisomy 21

down syndrome - mental retardation, brachcephaly, prominent epicanthal folds, brushfield spots, poor nasal bridge development, congenital heart disease, hypotonia, hypermobility of joints, characteristic dermatoglyphics -most frequent abnormality related to a chromosome abnormality - positive correlation b/n the frequency of down syndrome and maternal age

gonorrhea dx and tx

dx: - standard: **nucleic acid amplification - **gram stain - culture on modified **thayer martin media using swabs tx - ceftriaxone and azithromycin (doxycycline if macrolide allergy - **growing resistance to all three drugs

early vs late findings of breast cancer

early - single - nontender - firm to hard mass - ill defined margins - mammographic abnormalities - no palpable mass late - skin or nipple retraction - axillary lymphadenopathy - breast enlargement - erythema - edema - pain -fixation

trichomonas vaginalis presentation

females - asymptomatic in many - vaginitis with **frothy gray to yellow-green vaginal discharge, **pruritis, **cervical petechiae/ strawberry cervix - may infect skene's glands and urethra, these cases not amenable to topical tx males - cause nongonococcal urethritis - associated with an increased shedding of HIV in infected pt - **frequently asymptomatic

serum tests screening for trisomy 21**

first trimester markers - PAPP-A: protein encoded by the PAPPA gene, low levels can be found in cases of trisomy 13, 18, 21 or placenta abortion second trimester markers - AFP: protein made by the yolk sac, fetal GI tract and fetal liver: peaks in amniotic fluid 12-14 wks and in maternal serum 15-18 wks, low in trisomies, elevated in NTD - inhibin: protein made by the placenta and inhibits FH secretion - beta hCG: twice as high in pregnancies affected with down syndrome - uE3/ estradiol

WHITE'S classification system for diabetes severity

gestational DM - A1: diet control - A2: medications: insulin or oral overt DM - B: onset >20 yo, duration less than 10 yrs - C: onset 10-19 yo, duration of 10-19 yrs - D: onset less than 10 yo, duration more than 20 yrs - E: overt DM w/ calcified pelvic vessels - F: diabetic neuropathy - R: proliferative retinopathy - RF: retinopathy and nephropathy - H: ischemic heart disease - T: prior kidney transplant

FDA recommendations for menopause tx

goals - lowest dose possible - for the shortest duration needed - to achieve desired effect indications - hot flashes moderate to severe - vulvar vaginal atrophy - osteoporosis tx for women who cannot take non estrogen alternatives - not to prevent CV disease

causes of acute pelvic pain

gynecologic*** -acute infections: PID, endometriosis - adnexal accidents: ovarian cyst, torsion, rupture, hemorrhage - pregnancy complications: ectopic, miscarriage, abortion nongynecologic - GI: appendicitis, enteritis, intestinal obstruction - GU: cystitis, ureteral stones, urethral syndrome - other: MS, pelvic thrombophlebitis, aneurysm, porphyria

obstetrics cardiac output changes

increases 40% - plateaus about 20-24 wks - thought to be due to hormonal influences as well as the AV shunt effect of uteroplacental circulation -max CO is associated with a 24% increase in stroke volume and a 15% increase in HR - multiple gestations have even more increased CO, in twin pregnancies CO is about 20% greater say NO to supine position - in the third trimester, the supine position can reduce CO and arterial pressure caused by compression of the vena cava by the gravid uterus with an associated reduction in venous return to the heart - pt may develop supine hypotension syndrome, characterized by hypotension, bradycardia, and syncope - shifting the gravid to a lateral recumbent position will alleviate caval compression, increase blood return to the heart, and restore CO and arterial pressure

obstetrics blood volume changes

increases 50% - estrogen from the placenta stimulates the RAS system, which leads to more aldosterone: Na and H2O reabsorption - begins early in the first trimester, increases rapidly in the second trimester, and plateaus at 30 wks - human somatomammotropin, progesterone, and other hormones cause a 30% increase in RBC mass - increased blood volume, or hypervolemia of pregnancy, is critical to compensate for blood loss during delivery

obstetrics liver changes

liver morphology does not change in normal pregnancy

osteopathic tx in ob/gyn

look for somatic dysfunction in pts - pelvic pain: adhesions, endometriosis, ovarian cysts, malignancy (don't use OMT), somato visceral reflexes to the pelvis (piriformis, psoas syndrome) - dysmenorrhea - dyspareunia - urinary disease - any disease process that produces pelvic pain will produce a hypertonus state in the pelvis - visceral afferent pain pathways from the uterus, tubes, and ovaries enter T11 and T12, a pt may present with referred pain in these dermatomes - sympathetic innervation to the uterus, tubes, and ovaries are by the inferior hypogastric plexus - parasympathetic innervation to the uterus, tubes, and ovaries are by S2-S4 chapman's points - uterus: anterior points descending pubic rami b/l, posterior points L5 and sacrum b/l - ovaries: anterior points pubic arch b/l, posterior points T11 and 11th rib - fallopian tubes: femur trochanter **Indications: tension h/a, upper or lower back pain, sciatica (tx with sacral rocking), leg cramps, swelling (lymphatic tx), chapman's points, L&D

gestational DM risk factors and screening

low risk pt meet all of these criteria - less than 25 yo - not a member of a high risk ethnic group: hispanic, african, native american, south or east asia, pacific islands - VMI <25 - no hx of abnormal glucose tolerance - no previous hx of GDM - no DM in 1st degree relative screening - screen everyone - screen at about 24-28 wks gestation: this is an arbitrary date that attempts to dx glucose tolerance earlier than closer to term - insulin resistance increases as pregnancy progresses early screening - previous GDM: 33-50% likelihood of recurrence, screen at initial visit and if normal screen at 20-24 wks gestation - early persistent large glucosuria when not to screen - if T1 or T2 DM, no need - if 1 hr glucola >200, no need to perform 3 hr GTT, assue GDM - in pregnancy: a WHITE'S classification system is used to stratify DM severity and existing complications

fish that are safe to eat during pregnancy and great sources of important fish oils

lowest mercury: can have two 6oz servings per week anchovies, butterfish, catfish, clam, domestic crab, crawfish, croaker, flounder, haddock, hake, herring, mackeral (N atlantic, chub), mullet, oysters, perch, plaice, salmon (canned, fresh), sardines, scallops, shad, shrimp, sole, squid (calamari), tilapia, freshwater trout, whitefish, whiting

osteoporotic fractures risk factors

major - fragility/ compression fx - FHx of osteoporotic fx - glucocorticoid therapy longer than 3 months - malabsorption syndrome - primary hyperparathyroidism - fall risk - hypogonadism - early menopause <45 yo minor - RA - PMHx hyperthyroidism - anticonvulsant tx - low Ca intake - smoker or excessive alcohol/ caffiene - wt <170 lb or >10% loss - chronic heparin tx modifiable - smoking, nutrition, BMI, alcoholism, inadequate physical activity, long term poor Ca/vit D intake, estrogen deficiency, chronic steroid use, impaired eye sight non modifiable - genetics, prior hx, race race - caucasion and asian, african american women have 6% higher bone density

gestational DM complications

maternal - more likely to develop HTN disorders: preeclampsia, eclampsia, HELLP - more likely to have C section - increased risk of DM later in life by 50% fetal - macrosomia due to baby bringing in extra glucose causing them to put on weight: operative delivery, shoulder dystocia, birth trauma - hyperbilirubinemia - neonatal hypoglycemia - fetal heart block - obesity and DM later in life

combined oral contraceptives mechanisms

mechanisms of action - suppression of hypothalamic GnRH and pituitary gonadotropin secretion - **inhibition of the midcycle LH surge, so that ovulation does not occur - suppression of ovarian folliculogenesis via suppression of pituitary FSH secretion progestin related mechanisms - effects on the endometrium, rendering it less suitable for implantation - alterations in cervical mucus, which becomes less permeable to penetration by sperm - impairment of normal tubal motility and peristalsis

female sterilization methods

minilaparotomy - small infraumbilical (postpartum) or suprapubic incision - ligate and excise portion of tube - postpartum tubal ligations most effective lapaoscopy - small 1 cm infraumbilical incision - clips, silicone rings, electrocautery transcervical

syphilis dx

nontreponemal - **RPR/ rapid plasma reagin and **VDRL/ venereal disease research lab; based upon reaction to cardioplipin cholesterol lecithin ag, reported as titer of ab, cheap and used as screening tool -false positives: pregnancy, immunization, autoimmune disorders, infection, HIV, liver disease treponemal test - many types, now less expensive - used to **confirm positive treponemal test - **FTA-ABS most common - remains positive for life

women found to have increased risk of aneuploidy with first trimester screening should be....

offered genetic counseling and the option of CVS (chorionic villus sampling) or second trimester amniocentesis

preeclampsia divisions**

preeclampsia - systolic >140, or diastolic >90 - **Plus ssx or proteinuria - urinary excretion of >.3 g protein ina 24 hr urine specimen preeclampsia with severe features - systolic >160, diastolic >110 o 2 separate occasions while on bedrest - progressive renal insufficiency: serum creatinine >1.1 mg/dL or a doubling of baseline values - cerebral or visual disturbances: H/A, scotomata - pulmonary edema or cyanosis - persistent epigastric or RUG pain - impaired liver enzymes: liver enzymes doubling normal concentrations - thrombocytopenia: platelets <100,00

abnormal genetic screening then what next**

remember just a screening tool - false positive rate of quad screen: 83% - add 1st trimester screen: 87% - add targeted US: 94-96% dx testing -2nd trimester amniocentesis: send for chromosomal analysis - chorionic villus sampling

wolf's syndrome

short arm chromosome 4 deletion - severe growth and mental retardation, midline scalp defects, seizures, deformed iris, beak nose, hypospadias

cri-du-chat syndrome

short arm chromosome 5 deletion - microcephaly, catlike cry, hypertelorism with epicanthus, low set ears, micrognathism, abnormal dermatoglyphics, low birth weight

intimate partner violence/ IPV.... why is this important for doctors to know

studies have shown that training can: increase doc self efficacy to ID and help IPV victims and increase their comfort with addressing the health concerns, with asking pt difficult questions, with not giving up on a difficult pt, and making appropriate referrals

trisomy 13

the D syndrome - severe mental retardation, congestive heart disease, polydactyly, cerebral malformation, eye defects, low set ears, cleft lip and palate, low birth weight, characteristic dermatoglyphic pattern

trisomy 18

the E syndrome, Edward's syndrome - severe mental retardation, long narrow skull with prominent occiput, congenital heart disease, flexion deformities of fingers, narrow palpebral fissures, low set ears, harelip and cleft palate, characteristic dermatoglyphics, low birth weight

chlamydia trachomatis complications

women - most asymptomatic - **cervicitis: most common site, irritated, friable, inflamed, discharge - **urethritis - **PID: fever, tenderness, adnexal fullness - **Fitzhugh-Curtis syndrome/ perihepatitis: inflammation of the liver capsule and surface of liver from severe PID, LFT remain normal, RUQ pain main complaint - **infertility: single most common cuase - **PROM and preterm labor, ectopic pregnancy - proctitis men - rare - urethritis: most common cause of nongonococcal urethritis in men - epididymitis - prostatitis - proctitis - **reactive arthritis triad/ RAT: arthritis, uveitis, urethritis common to men and women - conjunctivitis: direct inoculation with discharge - pharyngitis rare - **genital lymphogranuloma venereum/ LGV: non painful genital ulcer followed by inguinal **buboes

uterine leiomyomas/ fibroids

• **Most common pelvic tumor in females. Monoclonal tumors arising from smooth muscle cells of the myometrium in reproductive age women. Incidence by age 50 of >80% for Black women, 70% for white women. • Described as to **uterus location: submucosal, intramural, subserosal, cervical. • **Symptoms: abnormal bleeding, pelvic pressure/pain, and reproductive dysfunction(infertility). • **Pelvic exam and TVUS for diagnosis, unless a malignant lesion is suspected (e.g., uterine sarcoma) • Symptom relief when patient reaches **menopause but hormone use after menopause may act to increase size. • Surgery **(hysterectomy) remains mainstay of treatment. Medical management may be complicated and no established single treatment for all fibroid patients currently available. Uterine fibroid embolization(UFE) produces significant decrease in fibroma size; it is useful for those in child bearing years and not wanting pregnancy

ectopic pregnancy

• Ectopic = extrauterine pregnancy; 84% in fallopian tube; other sites include cervical, interstitial, cesarian scar, ovarian or abdominal. • Early first semester vaginal bleeding/pain. Tubal rupture can quickly lead to life-threatening hemorrhage. • Consider ectopic: when pt is pregnant but has not had confirmed intrauterine pregnancy, pregnancy status uncertain, and when female in reproductive years present unstable and an acute abdomen when no other diagnosis explains symptoms. • Serial HCG: normal HCG doubles every 72 hours. Ectopic HCG does not rise as fast. • Diagnosis: Clinical with positive HCG & TVUS showing no IUG and or blood in the pelvis if leaking/ruptured. • Treatment: Methotrexate (MTX) or surgical intervention. • MTX candidates: hemodynamically stable, no contraindications to MTX, HCG below or equal to 5000 mlU/mL, no fetal cardiac activity on TVUS, willing/able to comply with post-treatment follow-up. Ectopic mass size of 3 to 4 cm is also used by some for patient selection as well.

endometriosis

• Endometrial **glands & stroma occurring outside the uterine cavity. Pathogenesis appears multifactorial. • Endometriosis is associated with **risk for poor pregnancy outcomes, ovarian cancer, and atherosclerosis. • **Presentation: reproductive years; most common pelvic pain from mild to severe (dysmenorrhea & dyspareunia), infertility, and/or ovarian mass. Less common bowel / bladder dysfunction, abnormal uterine bleeding, low back pain, chronic fatigue. Range from asymptomatic to severe symptoms. • **Exam: posterior vaginal fornix tenderness; palpable/tender nodules in posterior cul-de-sac, uterosacral ligaments or rectovaginal septum; lateral displacement of the cervix; fixation of the cervix, adnexa, or uterus; and/or tender adnexal mass. • **Does not cause any diagnostic lab findings (but may cause a serum cancer antigen CA 125 elevation but it is not used for diagnosis of endometriosis) • **Imaging may include TVUS, AUS, MRI. Definitive diagnosis is surgical biopsy. • Treatment: NSAIDS, OC, Gonadotropin-releasing hormone (GnRH) agonists; surgical treatment includes laparoscopic excision, fulguration or laser vaporization of implants/adhesions.