OBGYN

Palpable adnexal mass

Pelvic ultrasonography is the first line test for evaluation of adnexal mass (may arise from ovary or Fallopian tube). CA-125 has low specificity for initial screening of ovarian cancer in premenopausal pts

shoulder dystocia

blockage or difficulty of delivery due to obstruction of the birth canal by the infant's shoulders, risks: fetal macrosomia, Most common type of brachial plexus injury is Erb-Duchenne palsy C5-7. waiter's tip-- management:observation & physical therapy

tubo-ovarian abscess (TOA)

complication of PID. presents with fever, abd pain, & a *complex* *multiloculated* adnexal mass with *thick walls* and internal debris. Polymicrobial infection. complex mass to create a pyosalpinx & TOA. Labs: leukocytosis, C-RP, CA-125, fever

Short interpregnancy interval (IPI)- <6-18months complications

complications: maternal anemia preterm labor PPROM low birth weight

hydatidiform mole

*Preeclampsia at <20 weeks* hCG levels above 100, 00 mIU/mL, and an enlarged bleeding uterus Partial: 69XXX or XXY --- complete egg + 2 sperms Complete: 46 XX, XY, YY -- empty ovum + 2 sperms or empty ovum + 1 sperm that duplicated

Acute cholangitis

*Ascending Infection* of the biliary tree *d/t obstruction* fever, jaundice, RUQ pain, +/- hypotension *Inc direct bilirubin, ALP*, mildly inc transaminases, biliary dilation on abd US or CT Abx for enteric bacteria biliary drainage by ERCP within 24-48h

Once pregnancy is excluded, the workup of primary amenorrhea involves evaluation of

*FSH, TSH, prolactin* development of secondary sexual characteristics, such as breast development, a pelvic ultrasound or physical exam to confirm the presence of a uterus and normal vagina, a follicle-stimulating hormone (FSH) level to evaluate for ovarian failure or chronic anovulation, thyroid stimulating hormone to rule out thyroid disease causing amenorrhea, and a prolactin level to rule out a prolactinoma.

Gravity/Parity breakdown.

*Gravity* = # of times pt pregnant *Parity* = what happens to the pregnancy TPAL 1. *T*erm births 2. *P*reterm births 3. *A*bortions (both spontaneous and induced) 4. *L*iving children (if pt has a multiple gestation pregnancy, one birth results in 2 children)

Endometrioma

*Homogeneous* cystic ovarian appearance on ultrasound

Beckwith-Wiedemann Syndrome (BWS)

*Imprinting*; caused by having 2 active copies of region 11p15, when maternal should be imprinted; usually sporadic; WT2 mutation; can be caused by maternal chromosomal rearrangements, *paternal uniparental disomy*, or abnormal methylation; *macroglossia*, high birth weight and length- hemihyperplasia, umbilical hernia, *increased risk of cancer*-- specifically Wilms Tumor *Polyhydramnios, macrosomia, omphalocele*

Dysgerminoma

*LDH*- Tumor composed of large cells with *clear cytoplasm and central nuclei* (resemble oocytes); *most common malignant germ cell tumor*

gestational diabetes

*Screen 24-28w* Increased *insulin resistance* is a physiologic change of pregnancy d/t increased levels of *placental somatomammotropic (human placental lactogen)* production. Gestational diabetes occurs when insulin resistance exceeds production & results in maternal hyperglycemia. The macrosomia and pulmonary disease most closely related to an increase in serum insulin concentration.

Hep B in pregnancy

*Tenofovir* is first line. *Can breastfeed* if appropriate neonatal prophylaxis

postpartum endometritis treatment

*clindamycin and gentamicin* due to broad spectrum coverage is a polymicrobial infection characterized by fever >24h postpartum, purulent lochia & uterine tenderness

Needle aspiration for cytology

*contraindicated in postmenopausal women with an adnexal mass* d/t risk of spreading potentially malignant cells if mass prove cancerous.

HELLP syndrome hemolysis Elevated liver enzymes low platelets

*hepatic & systemic inflammation*, activation of coagulation cascade & platelet consumption. if stable, <34w --> admin 48 corticosteroid then deliver

Non classic (late-onset) CAH

*hyperandrogenism* & *elevated 17-hydroxyprogesterone*. mainly d/t partial *deficiency in 21-hydroxylase*--> *** impaired conversion of 17-OHP --> 11-deoxycortisol. Buildup of *17OHP is diverted toward adrenal androgen synthesis* --> hyperandrogegism. presents in *adolescence or early adulthood* with irregular menses, severe acne, hirsutism, virilization is rare. Sufficient gluco & mineralocorticoid are produced so not have salt waisting as classic CAH, BP is normal.

Antiphospholipid syndrome CI

*hypercoagulable state*, characterized by *vascular thrombosis* & pregnancy complications. Its an absolute *contraindication to hormonal contraceptives*. Only hormone free options: *copper IUD or tubal ligation*

amniotic fluid embolism

*respiratory failure* from amniotic fluid embolism syndrome (AFES) complication *during pregnancy or shortly after delivery*. Risk: advanced maternal age, high gravid (>5 live births or stillbirths) Amniotic fluid enters the maternal circulation --> *inflammatory response* causing *vasospasm, cardiogenic shock, hypoxemic respiratory failure, & coagulopathy with DIC*. Treat: supportive to correct hypoxemia (intubation, mechanical ventilation) & hypotension (vasopressors)

Delivery with chickenpox.. tx newborn with:

*varicella-zoster immune globulin* therapy *for pts who are exposed to varicella & lack evidence of varicella immunity* (neg IgG Ab, no hx of childhood infection). The varicella zoster vaccine is live attenuated, contraindicated in pregnancy.

colonoscopy screening guidelines

- *average risk* population starting at *50-75* - if there is *family history in a primary relative, earlier (10 years younger than the age of relatives diagnosis* - i.e. mother diagnosed at 50, get screening at 40)

AEDs and pregnancy

- All AED's are teratogens -*Increase dosage* as needed do to *increased Vd in pregnancy* -*Do not switch drugs* except for few exceptions -*Supply folic acid* to dec teratogenic CNS effects

Urethral diverticulum

- Localized outpouching of urethra into anterior vaginal wall- inflammation of surrounding tissue. - Well circumscribed, isolated cystic mass that can collect urine. Sx: dysuria, postvoid dribbling, dyspareunia, tender anterior vag wall with purulent or bloody discharge.

gestational diabetes tx

- diet modification & exercise are first line - 2nd line- insulin, metformin. If nutritional therapy fails to produce euglycemia, insulin or oral anti-diabetic medications are indicated.

Neonatal thyrotoxicosis (neonatal Graves disease)

- transplacental passage of maternal anti-TSH receptor Abs - Ab bind to infants TSH receptors and cause excessive thyroid hormone release - features: warm moist skin, tachy, poor feeding, irritable, poor birth weight - Dx: maternal *anti-TSH receptor antibodies* > 500% normal Tx: *self resolves* within *3 months*/ methimazole + B blocker

Changes before labor

-lightening: fetal descent into pelvic brim -Braxton Hicks contractions (inc toward end of pregnancy) -Bloody show: released from vagina with cervical effacement

Duplex venous ultrasonography

-noninvasive test used to visualize the vein and measure the velocity of blood flow in the veins used for varices in pregnant woman

first trimester

0-14 weeks

postpartum psychosis

0.1- 0.2% incidence rate. Characterized by mood-congruent delusions, hallucinations, and *thoughts of harming the baby or self*. Risk factors: history of bipolar or psychotic disorder, first pregnancy, family history, recent discontinuation of psychotropic medication. Treatment: *hospitalization* and initiation of *atypical antipsychotic*; if insufficient, *ECT* may be used.

telangiectasias/ palmar erythema

Small BVs/reddening of the palms- first trimester

4 signs of placental separation

1. gush of blood. 2. cord lengthening. 3. globular and FIRM uterus. 4. uterus rises anteriorly/ uterine fundus lowers should occur w/in 30 mins of delivery

MDD with peripartum onset

10- 15% incidence rate. Formerly known as postpartum depression. Characterized by depressed affect, anxiety, and poor concentration for *>2 weeks*. Treatment: *CBT and SSRIs* are first line.

chorionic villus sampling (CVS)

10-13 weeks A technique associated with prenatal diagnosis in which a small sample of the fetal portion of the placenta is removed for analysis. can use for multiple gestation screening as well

chorionic villus sampling (CVS)

10-13w if genetic aneuploidy screen(+) obtains fetal karyotype done transabdominally or transvaginally

second trimester

14-28 weeks

amniocentesis

15-17w Amniocentesis has the added benefit of screening for neural tube defects. If there is enough risk for a neural tube defect, sampling amniotic fluid combined with ultrasound study are done to screen for any defects.

third trimester

27w: CBC - if Hgb<11 replace iron orally (give stool softener with iron as iron inc constipation) 24-28w: 1hr glucose challenge test (GCT), if >130-140 at 1 hr do OGTT 36w: culture for chlamydia/gonorrhea STD testing if high risk pt culture GBS

third trimester

28 weeks to delivery Term - 37 - 41 weeks Preterm - 22-36 Before 22 weeks (previable) no resuscitation After 25 weeks + : resuscitate always 23-25 week: case-by-case

Recurrent fetal loss

3 consecutive miscarriages that occur before 20 weeks gestation. Possible causes: Genetics factors- aneuploidy Anatomical factors- bicornuate uterus, cervical insufficiency Endocrine- thyroid prob, hyperprolactinemia Immunological factors-SLE, anti phospholipid syndrome Thrombophilia- factor 5 Leiden mut, prothrombin mutation

PCOS (polycystic ovarian syndrome)

3 criteria (2 of 3 to dx) -Hyperandrogenism: acne, hirsutism, androgenic alopecia. -hx of irregular menses (indicates anovulation) -polycystic ovaries on US multiple eggs develop, but none ovulate; amount of estrogen production not normal; related to weight gain, dislipidemia, and diabetes

postdural puncture headache

After lumbar puncture or neuroaxial anesthesia unintentional *dura puncture* may occur causing *CSF leakage*— low CSF fluid Pressure— resultant *slight herniation* of the brain and brainstem. *Within 72h of procedure* *Positional HA* Neck *stiffness* *Photophobia, diplopia* Hearing loss, *tinnitus* Tx: typically *self limited*, epidural blood patch

cervical conization via cold knife or LEEP

tx for CIN grades 2 & 3. complications: cervical stenosis preterm birth PPROM second trimester pregnancy loss

Uterine Tachysystole

>5 contractions /10mins ---> uterine contractions interrupt intervillous BF; excessively frequent cntxs -->decreased uteroplacental BF during contractions & inadequate recovery time between contractions -> recurrent late decelerations (sign of uteroplacental insufficiency-- fetal hypoxemia & acidemia). can occy in spontaneous labor, but increased risk with induced or augmented labor (uterotonic agents). manage with lateral maternal repositioning, tocolysis, & discontinuation of uterotonic agents (oxytocin)

Postpartum blues (baby blues)

50- 85% incidence rate. Characterized by depressed affect, tearfulness, and fatigue starting 2- 3 days after delivery. Usually resolves within 10 days. Treatment: supportive. Follow up to assess for possible MDD with peripartum onset.

fetus

8w to birth

fetal bradycardia causes

<110/min. Maternal hypothermia, Meds SE, fetal hypothermia, fetal hypothyroidism, fetal heart block

Normal postvoid residual volume

<150mL in woman; <50mL in man

short inter-pregnancy interval

<6-18months from delivery to next pregnancy Complications: Preterm delivery PPROM Low birth weight Maternal anemia Interval contraception recommended for adequate maternal recovery& optimization for future pregnancies

Asymptomatic Bacteriuria (ASB)

>/=100K CFUs of single bacteria in clean catch urine specimen. In pregnancy increased progesterone--SM relaxation and ureteral dilation- inc risk for ascending infection (acute pyelonephritis). also risk of preterm labor & low birth weight. E.coli most common pathogen. All women are screened for ASB at their initial prenatal visit. First line Ab's: cephalexin, amoxicillin-clavulanate, & nitrofurantoin.

amniocentesis

>15-20w needle puncture of the amniotic sac to withdraw amniotic fluid for analysis

fetal tachycardia causes

>160/min. Maternal fever (intraaminiotic infection), meds SE, fetal hyperthyroidism, fetal tachyarrythmia

MCA Doppler

>20w diagnose fetal anemia

PUBS (percutaneous umbilical blood sampling) or cordocentesis

>20w but <32w fetal anemia diagnose & treat

Endometrial biopsy indications

>45 AUB, Postmenopausal bleeding <45 AUB + unopposed estrogen (obesity, anovulation)/ failed medical management/ Lynch syndrome >35 Atypical glandular cells on Pap test

UTI urine dipstick

A clinical diagnosis of urinary tract infection is made in patients with symptoms supported by the presence of pyruria and/or bacteriuria. A urine dipstick are often used to quickly confirm this diagnosis. Leukocyte esterase is an enzyme released by leukocytes and is an indicator of pyuria. A positive leukocyte esterase corresponds to >10 leukocytes/hpf. Nitrite reflects the presence of Enterobacteriaceae species in the urine, a large family of gram negative bacteria that include many pathogen commonly implicated in urinary tract infections (e.g. Eschericia coli). Enterobacteriaceae species convert nitrate to nitrite, which is detected on the urine dipstick. Patients with positive leukocyte esterase and negative nitrites can have urinary tract infections with pathogens that are not Enterobacteriaceae such as S. saprophyticus, a common cause of UTIs in sexually active women. Hematuria is commonly seen in the setting of urinary tract infections; it is not associated with a complicated infection.

benign mucinous ovarian cyst

A mucinous ovarian cyst appears on pelvic ultrasound as a *large, thin-walled cyst* containing fluid. These cysts *can be multi-loculated as well but contain homogenous appearing fluid* throughout. Mucinous cystadenomas are *benign but can grow very large*, ranging from 5 to 20 cm in size. Management of a large, symptomatic pelvic masses is surgical removal. Treatment of mucinous cystadenomas includes unilateral salpingo-oophorectomy, as often the ovary cannot be salvaged due to the large size of the cystadenoma, or total abdominal hysterectomy-bilateral salpingo-oophorectomy if the patient is postmenopausal.

uterine inversion

A potentially fatal complication of childbirth in which the placenta fails to detach properly and results in the uterus turning inside out. from excessive fundal pressure & traction on the umbilical cord before placental separation. typically accompanied by *hemorrhagic shock* & lower abd pain

breast cancer

A woman has 1 in 8 lifetime risk of breast cancer. *Alcohol* consumption is a *dose-dependent risk factor*, & reduced intake will decrease the risk of breast cancer. *Protective* lifestyle aspects include *exercise* (obesity-->less peripheral estrogen) & *breastfeeding*.

Lynch Syndrome (HNPCC)

AD DNA *mismatch repair* mut --> *microsatellite instability*. 80%---> CRD assoc: colon, ovarian, endometrial, skin

Epidural anesthesia

AE: hypotension d/t sympathetic nerve fibers responsible for vascular tone are blocked--> vasodilation (venous pooling). infusion to epidural space at the L2-L5

ALT AST

ALT: 8-40 AST: 8-40 ALP M: 30-100/ F:45-115

VTE Venous thromboembolism

All medicines with *estrogen agonist activity* (OCPs, HRT, SERMs) increase the risk for VTE. current or prior VTE disorders are contraindications to both raloxifene & tamoxifen use

5 alpha reductase deficiency

AR, affects males; inability to convert testosterone to DHT. appear phenotypically female at birth. develop virilization at puberty (clitoromegaly) & have no breast development. testosterone and estrogen levels are NORMAL

Abortion vs IUFD intrauterine fetal demise

Abortion: pregnancy ends before 20w or fetus <500g IUFD: fetal death >/=20w & before labor onset

Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)

Absent uterus & cervix, ovaries & external genitalia are good-- normal FSH levels (normal ovarian function). The paramesonephric ducts form the uterus, fallopian tubes & cervix. The mesonephric (wolffian) ducts form primitive kidneys. Common embryologic source & synchronous development-- renal abnormalities. Perform a renal US

Tocolytics (5)

Act on uterine muscle to *cease contractions*. Used to stop preterm labor. *Terbutaline* sulfate (Brethine), -- b agonist *ritodrine* HCl (Yutopar), *nifedipine* (Procardia), *magnesium sulfate* *Indomethacin* *At >/= 34 weeks* gestation, *tocolytics are contraindicated*. Risks: indomethacin (oligohydramnios, closure of DA), nifedipine (maternal hypotension/tachycardia)

Initial obstetric visit

All new obstetric pts should undergo the following at their first visit: Full physical exam Pelvic exam (speculum & bimanual) Pap smear if no current available Tests ordered: CBC Blood type, Rh factor, *antibody screen via indirect anti globulin (Coombs) test* Syphilis screening test (RPR or VDRL) Chlamydea HIV HepB ASB -- UA Gonorrhea, HepC in High Risk pts

Screening

All pregnant women should receive screening for HIV, HBV, chlamydia trachomatis, & syphilis. for syphilis, universal screen at first prenatal visit

Pap smear

American Society for Cervical Cancer Pathology (ASCCP) guidelines recommend: *Cytology alone every three years in women age 21-29. *Guidelines for patients age 30-64 years: a Pap with HPV co-testing. If today's Pap is normal and HPV testing is negative, she will be due for a repeat Pap with HPV co-testing in 5 years.

Rubella

Any unvaccinated pt, should receive vaccination before becoming pregnant, since its a live attenuated vaccine it is recommended to delay pregnancy one month after vaccination

Serous cystadenocarcinoma

Ascites and a pelvic mass in a *postmenopausal woman* raises concern for an *epithelial ovarian cancer*. Cancers of the ovaries arise from epithelial cell origin in 95% percent of cases, and among the cancers of epithelial cell origin, *serous cystadenocarcinoma is the most common*. *psamomma bodies* Weight loss and early satiety are common complaints for these patients, who typically present late in the disease course. Because this patient has *ascites*, diagnostic paracentesis can be performed. Staging is done at the time of surgery.

intrauterine adhesions

Asherman's syndrome- infertility & secondary amenorrhea after intrauterine surgery. damage to endometrial basalts layer -->inflamed, denuded endometrium that causes the uterus to adhere to itself resulting in obliteration of the uterine cavity. the lack of endometrium --> secondary amenorrhea, infertility & a negative progesterone withdrawal test (despite normal estrogen and progesterone levels)

Obtain Follicle Stimulating Hormone level on day 3 of menses.. if suspect.. poi

Assessment of ovarian reserve is recommended in women over the age of 35, or in those women who have risk factors for premature ovarian insufficiency (for example, carriers of Fragile X). Women with adequate ovarian reserve produce inhibin B, which in turn inhibits production of follicle stimulating hormone (FSH). An elevated FSH on day 3 of the menses is evidence that there is a decrease in the number of follicles and oocytes, thereby leading to low levels of inhibin B, allowing FSH to peak early in the luteal phase. This patient is only 32-years-old and has no family history of infertility or Fragile X which would lead one to suspect decreased ovarian reserve.

oligohydramnios etiology (can't pee)

Associated with placental insufficiency, bilateral renal agenesis, posterior urethral valves (in males) and resultant inability to excrete urine. Any profound oligohydramnios can cause Potter sequence. diagnosis is oligohydramnios as there is decreased amniotic fluid and the infant has renal agenesis, bilaterally. The fetus is at risk for pulmonary hypoplasia due to increased pressure on the thorax. The musculoskeletal system is also affected by oligohydramnios.

Hx of genital herpes HSV infection in pregnant women

At 36w gestation until delivery antiviral prophylaxis (acyclovir, valacyclovir) regardless of symptoms.- reduces asymptomatic viral shedding & outbreak recurrences, decreases risk of vertical transmission. In asymptomatic pts on antiviral prophylaxis vaginal delivery is safe. Pts with symptoms or active lesions require C/S

Reactive NST results

At least two accels of FHR with fetal movement of 15bpm lasting at least 15 seconds or more in 20 mins (15 15) >32w <32w 10 x 10 it is reassuring or normal

GA dating

At less than 8+6weeks, the US date should be used if there is a discrepancy of 5 days or more

used to treat postoperative/neurogenic ileus and bladder atony (urinary retention).

Bethanechol is a direct cholinergic agonist that stimulates both the M2 and M3 receptors, components of the parasympathetic system. It especially favors M3 activation. Through stimulation of the M3 receptor, bladder contraction increases with concurrent bladder sphincter relaxation, which promotes urination.

infant

Birth to age 1

Chadwick's sign

Blue discoloration of vagina and cervix (6-8w)

Valproate vs lamotrigine

Both anticonvulsants and mood stabilizers. Valproate- neural tube defects *Lamotrigine* has favorable pregnancy safety profile-- preferred use during pregnancy

Breast fibroadenoma

Breast fibroadenoma is a common *benign, painless mass* often found in women between the ages of 15-35. They are *well-defined and mobile masses*, unlike malignant masses, which are the heterogeneously shaped and fixed. There is *no treatment needed*, as these are not malignant nor do they have malignant potential, but if the fibroadenoma grows rapidly, biopsy and excision are recommended to rule out malignancy.

Melasma

Brownish pigmentation of the face during pregnancy; also called chloasma and "mask of pregnancy" estrogen & progesterone stimulate melanocyte proliferation. irregularly shaped hyper pigmented macules of varying color, symmetric centrofacial, mandibular or molar distribution.

Aromatase deficiency -- elevated what?

Causes *maternal & fetal virilization* during ***pregnancy d/t placental inability to convert DHEAS to estradiol. will have elevated DHEAS- *dehydroepiandrosterone*

cervical insufficiency

Cervical insufficiency describes painless cervical dilation leading to recurrent pregnancy losses, typically during the second trimester. The pregnancy and fetal development itself are otherwise normal. History-based cervical insufficiency is diagnosed based on history of either ≥2 consecutive prior second-trimester losses, or ≥3 early (<34 weeks) preterm births. The appropriate treatment is transvaginal cerclage at 12 to 14 weeks and weekly intramuscular hydroxyprogesterone caproate injections from 16 to 36 weeks.

Along with Pap smear do...

Chlamydea and gonorrhea screening test

Multiple gestation screening test- CVS

Chorionic villus sampling is as accurate in twin pregnancies as in singleton gestations. increased risk for genetic anomalies including trisomies because of advanced age (≥35 years old at delivery). ultrasound shows a dichorionic, diamniotic twin pregnancy (note the "lambda" sign, the triangle of placental tissue between the two amniotic sacs, which indicates dichorionicity). Multiple gestations make serum testing less accurate, and nuchal translucency ultrasound alone is only 60-70% sensitive for trisomy 21. Given her increased risk, the inaccuracy of serum testing in multiple gestations, and her strong desire for accurate information early in pregnancy on which to base a decision about pregnancy termination, it is reasonable to pursue diagnostic CVS in this patient without first performing a screening test.

Intra-amnitotic Infection (Chorioamnionitis)

Complication with PROM (before onset of regular contractions) & prolonged membrane rupture (>18h). Signs: nausea, vomiting, fetal tachycardia (>160bpm), maternal tachycardia, maternal leukocytosis, purulent amniotic fluid. *polymicrobial infection* Tx: broad spectrum ***Abx (ampicillin, gentamicin, clindamycin) & immediate ***delivery via augmentation of labor

PROM- gush of fluid- leads to:

Cord prolapse Uterine abruption Preterm labor Chorioamnionitis (avoid multiple digital rectal exams to avoid it)—- I'd have CA deliver now

Trisomy 18

Low birth weight closed fists with index overlapping 3rd digit and 5th digit overlapping 4th Rocker bottom feet Microcephaly micrognathia intellectual disability cardiac (VSD) and renal malformation d/t meiotic nondisjunction

preterm treatment

Corticosteroids given to patient less than 34 weeks of gestation. Corticosteroids are considered the single most beneficial intervention for improvement of outcomes among preterm neonates, as they decrease the risk of respiratory distress syndrome, intracranial hemorrhage, and necrotizing enterocolitis. Magnesium sulfate used in patients less than 32 weeks of gestation for neuroprotection, as studies have demonstrated that it decreases the risk of cerebral palsy.

Intrauterine fetal demise IUFD

Death of fetus >/=20 weeks Pt present w/ decreased or absent fetal movement Diagnosis MUST be confirmed by absence of fetal cardiac activity on ultrasound

Betamethasone

Corticosteroid - effect writhing 24h peaks at 48h and persists 7d When steroids are administered, a tocolytic should follow to allow time for them to work. CCBs are the preferred tocolytic—> inhibit MLCK—> myometrial relaxation Terbutaline- beta R agonist , leads to increased maternal HR

Late decelerations (most dangerous)

Delayed compared to contraction- nadir of deceleration occurs after peak of contraction, Gradual (>30s from onset to nadir) Etiology: Uteroplacental insufficiency: compression of maternal BVs->dec placental perfusion-> dec placental perfusion- fetal hypoxia

overflow incontinence tx

Doxazosin is an α-1 selective antagonist used to treat overflow incontinence. Patients with overflow incontinence present with perpetual urine dribbling and low urine flow. Overflow incontinence is caused by either impaired detrusor muscle contractility (e.g., diabetic neuropathy) or obstruction of the bladder outlet (e.g., BPH).

Gonococcal infection Tx

Dual tx with ceftriaxone & Azythromycin Ceftriaxone monotherapy is no longer recommended for the treatment of urogenital gonococcal infections given the increased incidence of N. gonorrhoeae resistance. Azithromycin should be included in all patients; even those with a confirmed absence of chlamydia co-infection.

hematosalpinx

Ectopic pregnancy is the most common cause of a hematosalpinx (bleeding into the fallopian tubes). Endometriosis and tubal carcinoma are less common causes of hematosalpinx. Another less common cause of hematosalpinx is a transverse vaginal septum, which obstructs menstrual blood flow (cryptomenorrhea) and backs up in the fallopian tubes.

SLE nephritis in pregnancy

Edema, joint pain-arthritis, malar rash, HTN, UA with nephritic range proteinuria, *RBC & WBC cast, hematuria. Diagnose with renal biopsy. Pregnancy & postpartum period are associated with inc risk for SLE flares, in pts with hx of lupus nephritis. Pt's with SLE are *at risk for osteoporosis. First line agents: Calcium & Vit D, those at risk for fractures --> bisphosphonates (inhibit osteoclast activity- Alendronate, -dronates* Risk factors: discontinuation of hydroxychloroquine & active disease prior to conception. -distinguish from preeclampsia by decreased complement levels & increasing ANA titers. Inc risk for: (5) Preterm labor, C/S, preeclampsia, fetal growth restriction, fetal demise.

Non-reactive NST

NO ACCELERATIONS AT ALL fetus could be sleeping--> vibroacoustic stimulation is used to awaken the fetus

candida intertrigo

Erythematous *beefy red plaques within the inguinal folds*. Plaques in a symmetric kissing or mirror image pattern across skin folds and *multiple satellite lesions*. Most common cause is Candida albicans. Pts at risk- impaired immunity. Systemic corticosteroids use, DM, particularly *associating skin moisture or friction*. Tx with topical azoles <clotrimazole/ ketoconazole>

Nagele's Rule

Estimation of delivery date: LMP - 3 months + 7 days

Complications of Inappropriate weight gain in pregnancy

Excessive weight gain: G DM, fetal macrosomia, C/S Inadequate weight gain: preterm birth, fetal growth restriction

criteria for genetic testing to assess hereditary cancer risk include patients with:

Female breast cancer diagnosed at age 50 or younger Triple-negative breast cancer diagnosed at age 60 or younger Two or more primary breast cancers Invasive ovarian or fallopian tube cancer or primary peritoneal cancer Male breast cancer First-, second-, or third-degree relatives with breast cancer diagnosed at age 50 or younger

embryo

Fertilization to 8 weeks

Baseline fetal HR

Fetal tachycardia >160 bpm: Fetal hyperthyroidism Med side effect (b agonist) Fetal tachyarrythmia Maternal fever (IAI) Fetal bradycardia <110bpm: Maternal hypothermia Maternal hypothyroidism Med side effect (b blocker) Fetal heart block (anti Ro/SSA, anti La/SSB)

HTN tx in pregnancy

First line for HTN Crisis: all fast acting Hydralazine (vasodilator) IV Labetalol (b blocker with a block) IV - don't give to pt with bradycardia (pulse <60) as can lower pulse even further Nifedipine (CCB) oral - don't give pt with N/V may emesis since oral Methyldopa: treat CHRONIC HTN rather then HTN emergencies, slow onset

Asymptomatic Bacteriuria (ASB) Tx (4)

First line: Cephalexin Amoxicillin-clavulanate Nitrofurantoin Fosfomycin

1st trimester

First screening Fetal heart tones with doppler

Myositis ossificans

Formation of lamellar bone in extra skeletal tissues (muscle) Causes: trauma: muscle injury, fracture, ortho surgery neurogenic: stroke, Traumatic Brain injury, spinal cord injury Intramuscular mass with pain, swelling/induration Days/weeks following injury Lab: elevated ALK Phos, ESR, CRP Xray: periosteal bone reaction, calcification with radiolucent center Management: ROM exercise & NSAIDs surgical excision

2nd trimester

Genetic triple/quad screen (15-20w) triple: MSAFP, b-HCG, estriol quad: MSAFP, b-HCG, estriol, inhibin A increased AFP may indicate *dating error* (most common), neural tube defect, or abd wall defect Fetal movements (quickening) 16-20 w GA *Anatomic US 18*-20w

Mature cystic teratoma (dermoid cyst)

Germ cell tumor, most common ovarian tumor in females 20-30 years old. Cystic mass containing elements from all 3 germ layers (eg, teeth, hair, sebum). Can present with pain 2° to intermittent ovarian torsion d/t unstable suspension from IP ligaments. A monodermal form with thyroid tissue (struma ovarii) uncommonly presents with hyperthyroidism. diagnose with ovarian cystectomy which preserves fertility & reduces risk of torsion & malignant transformation.

HTN in pregnancy

Gestational HTN, Preeclampsia, eclampsia are BP >140/90 *AFTER 20 weeks* Hydatiform mole is HTN *before 20 weeks*

Hydatiform Mole

Gestational trophoblastic neoplasia - HTN before 20 weeks -Hyperthyroidsm---- LOW TSH - hCG that doesn't return to 0 after delivery/abortion/miscarriage or rises rapidly during preg - 1st or 2nd trim bleeding with poss expulsion of "grapes" from vag & excess N/hyperemesis G - Uterine size/date discrepancy - "Snow storm" on US Risk: extremes of maternal age Manage: D&C, contraception for 6mos

uterine atony tx

Given her exam, with the abnormally enlarged fundal height noted, it is likely that she is hemorrhaging secondary to uterine atony. She is not responding to oxytocin, so the next best step in her management would be to try an alternate uterotonic, in this case methylergonovine. Methergine acts by increasing uterine tone and causing contractions of uterine smooth muscle. Of note, methergine is contraindicated in patients with a history of hypertension. This is because it increases smooth muscle tone not only of the uterus, but also of the vasculature.

Leuprolide

GnRH agonist

G/TPAL

Gravida (pregnancies) P (parity): T (Term) P (Preterm) A (Abortions) L (Living)

cervical conization (cone biopsy)

HPV & tobacco risk factors for CIN --> SCC Colposcopy is gold standard for diagnosing CIN Cervical conization is the excision of the intact transformation is the recommended treatment for CIN 2 & 3. Complications: Cervical stenosis (scar tissue) Cervical insufficiency--> preterm labor Second trimester pregnancy loss Preterm premature rupture of membranes

Gardasil

HPV strains 16 and 18 are implicated in over 70% of cases of cervical cancer. HPV strains 6 and 11 cause condyloma acuminata (genital warts). The HPV vaccine Gardasil covers all four of the previously mentioned strains, however only 16 and 18 are linked to cervical cancer. HPV 1-4 cause benign skin warts on the hands and feet.

Hepatitis and pregnancy

Hep C mainly via exposure to infected blood. Pregnant women with chronic Hep C are gen asymptomatic. Acute viral hepatitis can be life threatening, especially in pts with pre-existing chronic viral hep. therefore all pts with chronic HCV should be immunized against Hep A & B. *Inactivated (killed) hep A & B* vaccines *safe to admin in pregnancy*.

postpartum depression

High incidence, all women regardless of prior psychiatric hx require screening for PPD. Via Edinburgh postnatal depression scale

TOA (tubo-ovarian abscess) tx

Hospitalization and parenteral therapy are recommended for at least 48-72 hours with transition to oral therapy when clear clinical improvement is observed. Intravenous cefoxitin every 6 hours plus oral doxycycline every 12 hours.

AE's of SERMs: Raloxifene, tamoxifen

Hot flashes VTEs Endometrial Hyperplasia & carcinoma (tamoxifen only)

Anogenital Warts (condyloma acuminata) in children

Human Papillomavirus infection HPV 6, 11 Sexual abuse (especially >4yo), auto inoculation from other sites, prenatal or perinatal. Pink/flesh colored, verrucous papule & plaques Asymptomatic (most common) Pruritic, friable masses

Hydatiform Mole (GTN-gestational trophoblastic neoplasia)

Hydatidiform mole is a form of gestational trophoblastic disease. It is caused by aberrant fertilization, either by two sperm or by a single sperm that has undergone duplication of the paternal haploid genome. Hydatidiform mole is not a viable pregnancy, and is considered a *premalignant lesion given its potential to progress to neoplasia. Symptoms of a hydatidiform mole include: vaginal bleeding, pelvic pain, hyperemesis gravidarum, thyroid storm, early preeclampsia. Hydatidiform mole can be diagnosed by noting a uterus that is abnormally enlarged for gestational age, a markedly elevated hCG (often > 100,000 mIU/mL, and always elevated relative to gestational age), and pelvic ultrasound demonstrating a classic "snowstorm" appearance of multiple small cystic spaces. A complete mole (with karyotype 46XX) 1 sperm duplicates, empty egg-will contain no fetal elements on ultrasound, whereas a partial mole (karyotype 69XXY, 69XXX, or 69XYY) may contain some fetal elements, heat beat. 2 sperm + 1 egg

Oxytocin AE:

Hyponatremia(136-145 normal)— HA, Abd pain, N/V, lethargy and tonic clonic seizure Hypotension Tachysystole Similar to ADH cause water retention and hyponatremia treat with hypertonic saline

Syphilis treatment

IM Penicillin G benzathine - required for all pregnant pts with syphilis to prevent fetal complication s. Pts with penicillin allergy should receive skin testing to confirm IgE mediated reaction, if positive, pts are desensitized prior to receiving treatment

Pyelonephritis treatment

IV ceftriaxone (after 48hrs can do oral Abx if doing better -- non-pregnant)

Digital cervical exam- no presenting fetal part

If in DCE theres a bulging bag with no presenting fetal part/indeterminate, a transbdominal US is performed to confirm presentation & help determine route of delivery.

AFLP management

Immediate delivery

Early postpartum

Immediately after placenta delivery, *shivering* occurs due to *thermal imbalance*. The *uterus contracts and becomes firm* with fundus 1-2 cm above or below umbilicus. *Lochia rubra* (vag discharge-shedding of uterine decidua)

Fetal hydrops

Inc *HOHF*, edema (third spacing) Pericardial/pleural effusion Ascites Skin edema Placental edema Polyhydramnios Etiology: *RhD alloimmunization* *Parvovirus * Fetal aneuploidy Cardiovascular abnormalities *Thalassemia major -Barts*

Primary dysmenorrhea (menstrual cramps)

Increased *endometrial prostaglandins* production causes uterine hypercontractility, hypertonicity, & resultant ischemia Results in cramps 1-2 days prior to menses and radiates to low back and thighs Systemic symptoms like nausea vomiting and diarrhea (prostaglandin induced stimulation of GI tract) First line are NSAIDS. Also can use OCPs

Physiologic changes in pregnancy

Increased BV--> increased preload, dec Hgb Increased cardiac output Increased heart rate Decreased SVR/TPR-->decreased afterload elevation of diaphragm-->dec RV unchanged FEV1/FVC Increased tidal volume-->inc minute ventilation -->dec pCO2--> respiratory alkalosis GE reflux (LES dec tone from progesterone effect) Constipation Increased GFR excess neutrophils, leukocytosis w/o infection gestational thrombocytopenia Anemia (inc plasma vol by 50% & RBC mass by 25%) Hypercoagulable state (inc fibrinogen)

Aromatase Deficiency

Increased androstenedione, dehydroepiandrosterone, testosterone prevents conversion of androgens to estrogens. It causes virilization of female fetuses, resulting in normal internal genitalia with ambiguous external genitalia.

Granulosa cell tumor

Increased estradiol & inhibin B call-exner bodies

Oxytocin

Induction/augmentation of labor Prevention & management of postpartum hemorrhage AE: hyponatremia, hypotension, tachysystole it is secreted by the posterior pituitary , similar in structure to ADH, so prolonged admin can cause water retention hyponatremia & resultant seizures.

signs of symptoms of endometriosis:

Infertility & 3 D's: painful menses (dysmenorrhea) and painful intercourse (dyspareunia), painful defecation (dyschezia). risk factors associated with endometriosis: *nulliparity* and a *low BMI*. Tx: NSAIDs (naproxen), OCPs, & Laparoscopy is both diagnostic and therapeutic, wherein laparoscopic ablation can remove lesions associated with endometriosis while maintaining fertility.

HRT indications in menopause (no menses in 12 mos)

Only current indication for HRT is vasomotor symptoms (hot flashes, sleep disturbances) in *women <60* who have undergone *menopause within the last 10 yrs*

All pregnant women w/o contraindications should receive the ____________ vaccine as soon as it becomes available. Its safe during every trimester of pregnancy & while breastfeeding.

Influenza . provides passive neonatal immunity

Alpha thalassemia major- Hemoglobin Barts chromosome 16

Inherited disorder of *absent alpha globin chain* production necessary to form Hb F. Fetuses with alpha thalassemia major *produce Hb Barts (4 gamma chains)* that *does not release oxygen* to tissues. Severe *hypoxemia, HOHF, hydrops fetalis (skin edema, ascites) and subsequent fetal demise*. Pleural effusion, pericardial effusion, skin edema, hepatomegaly

Labor second stage arrest

Insufficient fetal descent after pushing for 3/2hrs. Risks: maternal obesity, excessive pregnancy weight, DM. Etiology: cephalopelvic disproportion, malposition (non occiput anterior), inadequate contraction, maternal exhaustion

Krukenberg tumor

Krukenberg tumor is a *cancer that has metastasized to the ovary*. It is usually of *gastric or colonic origin*, but can also be *breast, lung, and contralateral ovary*. These tumor cells have the *"signet ring" appearance* and usually affect women of younger age.

Levothyroxine requirements in pregnancy

Levothyroxine requirements increase during pregnancy, pts with hypothyroidism should *increase their levothyroxine dose (30%) at the time pregnancy is detected*. In pregnancy *estrogen* induces an *increase in TBG*, requiring increase amount of thyroid hormone to saturate binding sites. Thyroxine production is also increased by stimulatory effects of hCG on TSH receptors--> increase in total thyroid hormone levels (won't occur in pts with pre-existing hypothyroidism)

Linea negra

Line of hyperpigmentation that can extend from xyphoid process to pubic symphysis

ACE-i & ARBs

Lisinopril is an angiotensin converting enzyme (ACE) inhibitor that is used in the treatment of hypertension and diabetic nephropathy. Since the use of ACE inhibitors in pregnant women can lead to fetal renal failure, these agents are generally avoided in pregnancy.

Lithium

Lithium is used in the treatment of bipolar disorder. In utero exposure to lithium can cause fetal cardiac malformations, most commonly Ebstein's anomaly. Ebstein's anomaly is a displacement of the tricuspid valve into the right ventricle. This can lead to tricuspid regurgitation and right heart failure. Low thyroid heat anomaly diabetes Insipidus unwanted movement

Lymphogranuloma venereum (LGV)

Lymphogranuloma venereum (LGV) is a sexually transmitted infection, caused by any of three different serovars ( L1, L2, or L3) of the bacterium Chlamydia. The classic presentation of genital ulcers and lymphadenopathy is more common in tropical and subtropical developing countries, but should also be considered in returning travelers. LGV can also present with proctitis. The clinical course of LGV occurs in 3 stages. The primary stage occurs occurs at the site of inoculation. It commonly presents with a small, painless genital ulcers that often go unnoticed. The secondary stage occurs within 2-6 weeks after the initial lesion and presents large bilateral inguinal adenopathy. Lymph nodes commonly undergo liquefaction and develop into painful fluctuant buboes that rupture and drain pus. In the second stage, patients can also present with proctitis characterized by tenesmus and bloody purulent rectal discharge. If untreated, LGV can progress to fibrosis and strictures of the anogenital tract, frozen pelvis, infertility, and genital elephantiasis.

AFP abnormal results...

MS-AFP is routinely ordered at 15-20 weeks. The *most common cause of an abnormality on the test is a dating error.* Patients with elevated or low MS-AFP should undergo *ultrasound* to *verify clinical dating* as well as to *visualize any anatomic defects.* Those with elevated MS-AFP may have a more advanced gestational age than originally suspected or neural tube defects; those with low MS-AFP may have a true gestational age that is less than originally suspected (however, patients with low MS-AFP may also have Down syndrome). If ultrasound shows a dating error, no further management is needed; if dating is correct and ultrasound shows the cause of the abnormality (twins, neural tube defects, renal abnormalities), then no other follow-up is needed.

Preterm labor should not be stopped with tocolytics & delivery should occur if...

Maternal severe HTN (preeclampsia /eclampsia) Maternal cardiac disease Cervical dilation >4cm Maternal hemorrhage (abruptio placenta, DIC) Fetal death Chorioamnionitis

Meigs syndrome

Meig's syndrome is defined as the *triad* of: *pleural effusion*, and *ascites* in association with a *benign tumor of the ovary* The ovarian tumor is usually a fibroma. The ascites and effusion resolve after removal of the tumor.

Neonatal thyrotoxicosis Tx

Methimazole PLUS Beta-blocker

Luteomas of Pregnancy

Moderate maternal virilization (also seen in aromatase def) high risk fetal virilization Solid, unilateral/bilateral ovarian masses- benign spontaneous regression of masses after delivery due to falling b-HCG levels

Chancroid- haemophilus ducreyi

Multiple & deep ulcers. painful. Base may have gray to yellow exudate. organisms often clump in long parallel strands.

preeclampsia

New-onset hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg) + proteinuria (> 300 mg of protein in a 24-hour period) &/or end-organ damage occurring at > 20 weeks' gestation. Severe features: thrombocytopenia inc creatinine; inc transaminases Pulmonary edema Visual or cerebral symptoms PE: Edema of face, hands, feet confirm urine dipstick with: urine protein/creatinine ratio >/= 0.3 or a 24hr collection of total protein (gold standard) of >300mg Fetal complications for preeclampsia: oligohydramnios & fetal growth restriction/small for gestational age d/t chronic uteroplacental insufficiency

Preterm Premature Rupture of Membranes (PPROM)

Nitrazine + fluid causes ferrying on microscopy d/t NaCl. rupture before 37w before labor onset (contractions). Risks: prior PPROM, GU infections (BV, ASB), antepartum bleeding. Complications: Placental abruption (sheared BVs), Umbilical cord prolapse, preterm labor, intraamniotic infection

Management of placenta previa

No intercourse and pelvic rest No digital cervical exam Inpatient admissions for bleeding episodes Routine obstetric care as the majority resolve spontaneously

Androgen insensitivity Syndrome

Nonfunctioning androgen receptor results in genotypically males 46XY to appear phenotypically female. Present with primary amenorrhea (no ovaries) >15yo & male range testosterone levels--> have functioning cryptorchid testes that produce AMH & testosterone, have female external genitalia and breast development (testosterone aromatized into estrogen in puberty) & tall stature. Minimal to no axillary or pubic hair

Decreased fetal movement investigation

Nonstress Test (NST)- track FHR over time, noninvasive

Aromatase deficiency

Normal Internal genitalia, External virilization & undetectable serum estrogen levels in female. \ first manifests in utero with the inability of placenta to convert androgens--> estrogens ---> transient masculinization of the mom that resolves after delivery. Pts: osteoporosis, undetectable estrogen, delayed puberty & high conc of gonadotropins that result in polycystic ovaries.

Single Deepest Pocket (SDP) Assessment of Polyhydramnios vs Oligohydramnios

Normal SDP is 2-8 Oligohydramnios is <2 Polyhydramnios >8

Fetal Heart Rate (FHR) tracing

Normal: Baseline 110-160bpm moderate variability 6-25

Sheehan Syndrome

Obstetric hemorrhage complicated by hypotension. -- postpartum pituitary infarction. lactation failure (prolactin) amenorrhea, hot flashes, vaginal atrophy (FSH/LH) fatigue, bradycardia (TSH) Anorexia, weight loss, hypotension (ACTH) decreased lean body mass (GH)

Fetal malposition What is the optimal fetal position for delivery?

Occiput anterior

polyhydramnios etiology (no swallowing)

Often idiopathic, but associated with fetal malformations (eg, esophageal/duodenal atresia, anencephaly; both result in inability to swallow amniotic fluid), maternal diabetes, fetal anemia, multiple gestations. Perform *antenatal testing to find etiology*

At every prenatal visit...

Once detectable, measurement of the fetal heart tones by doppler should be performed at every prenatal visit

Atelectasis in pregnancy (lung collapse)

Over 90% of *low grade fevers in the first two** days after a surgery* are associated with *atelectasis*.

Methods of induction

PGE2 for *cervical ripening* Oxytocin- exaggerates uterine contractions Amniotomy- puncture of amniotic sac via amnio hook

Paget's disease of the breast

Paget disease, a rare breast cancer characterized by scaly, vesicular, or ulcerated lesions that begin on the nipple and spread to the areola. Other symptoms include bloody nipple discharge, nipple retraction, and sensations of pain, burning and/or pruritus. In 80 to 90% of Paget cases, there is an underlying breast cancer. In 50% of patients, a mass is palpable. In 20% of patients, an abnormality is detectable on mammography despite no palpable mass.

Placenta previa vs vasa previa

Painless vag bleeding after 20 weeks, non painful. Diff is vasa previa RAPID deterioration of FHR tracing as the hemorrhage is primarily of fetal origin in placenta previa blood loss is primarily of maternal origin therefore FHR tracing are typically reactive (normal) early in the disease process

Heterozygote for factor V leiden mutation

Patients who are heterozygotes for factor V Leiden without a history of prior VTE can be managed expectantly during pregnancy. However, women who are heterozygotes and have had a VTE previously should be on prophylactic LMWH or prophylactic UFH throughout the antepartum period and for 6 weeks postpartum, as the postpartum period carries a risk of VTE that is 2 to 5 times higher than in the antepartum period. Patients often prefer LMWH as it is once daily dosing compared to UFH which is twice daily dosing. Of note, if the patient is on LMWH, she should be converted to UFH at 36 weeks of gestation as the effects of UFH are faster to reverse, if needed, for epidural analgesia at the time of delivery.

Multiple Sclerosis lead to ______ type of urinary incontinence

Patients with *MS* most commonly develop *urge incontinence* due to the *loss of central nervous system inhibition of detrusor contraction* (detrusor hyperreflexia) in the bladder. --> As the disease progresses, the bladder can become atonic and dilated, leading to *outflow incontinence* Begins as *urge ---> overflow*.

Sickle cell in Pregnancy

Patients with sickle cell disease are considered a high risk pregnancy and have an increased risk of maternal and fetal complications, including an *increased risk of maternal mortality*. Patients with sickle cell disease have an increased risk of maternal and fetal complications. These complications include *increased maternal mortality, pneumonia, bacteriuria, sepsis, deep venous thrombosis, intrauterine growth restriction, preeclampsia/eclampsia, preterm labor, postpartum infection, abruption and antepartum bleeding*. The most common complications associated with pregnancy in patients with sickle cell disease are *anemia and acute pain crises* due to vaso-occlusion, occurring in 50% of women with sickle cell disease.

Risk factors for placental accreta/increta

Placenta previa and prior cesarean section are both risk factors for placental invasion through the endometrium and into deeper structures. placenta accreta, in which the placenta implants in the superficial myometrium instead of the decidual layer of the endometrium. placenta increta - invasion of the placenta through the endometrium and into the myometrium. This can progress to placenta percreta in which the placenta "perforates" the myometrium and invades the serosa, or adjacent structures such as the bladder. These abnormal placentas fail to detach from the uterine wall after delivery, leading to massive hemorrhage. Hysterectomy is often required at the time of delivery.

Multiple c sections complications

Placenta previa/accreta

DIC in Pregnancy found in:

Placental Abruption AFLP Amniotic Fluid Embolism

DIC complication of

Placental abruption Post partum hemorrhage Acute fatty liver of pregnancy AFLP Amniotic fluid embolism Presentation: sudden onset painful (abd or back pain) bleeding, Hugh frequency, low intensity contraction. Hypertonic, tender uterus.

Polyhydramnios & Oligohydramnios is AFI >/=

Polyhydramnios: AFI > 24cm; Oligohydramnios: AFI </=5 Normal Amniotic Fluid Index is 5-24

PALM COEIN for Ddx abnormal uterine bleeding

Polyps Adenomyosis Leiomyoma Malignancy Coagulopathy Ovulatory def Endometrial probs Iatrogenic Not otherwise classified

PPH

Postpartum hemorrhage is defined as over 500 mL of blood loss after a vaginal delivery or 1000 mL or more after cesarean delivery. Postpartum hemorrhage can be divided into primary and secondary hemorrhage. Primary postpartum hemorrhage occurs within 24 hours of delivery, and secondary (or delayed) postpartum hemorrhage occurs anywhere from after 24 hours postpartum to up to 12 weeks postpartum.

carpal tunnel syndrome (CTS)

Pregnancy (due to edema) Entrapment of *median nerve* in carpal tunnel (between *transverse carpal ligament* and carpal bones) - nerve compression - paresthesia, pain, and numbness in distribution of median nerve (*thumb, index, middle, and half the ring finger*). sensation spared, because palmar cutaneous branch enters hand external to carpal tunnel. Tingling, burning, or numbness, especially in your thumb and index or middle fingers Pain or numbness that worsens with: Wrist, hand, or finger movement Sleep (*symptoms may wake you*) Hand stiffness or cramping that gets better after: Shaking the hand Waking up in the morning Weakness or clumsiness of your hand: Loss of grip strength Difficulty touching your little finger with your thumb Frequently dropping things Pain extending up your arm

GERD (gastroesophageal reflux disease)

Pregnant patients with reflux will most commonly present with *nausea and epigastric pain*. The *nausea is typically worse after meals*, and the *epigastric pain typically worsens at night* due to the circadian changes in gastric acid secretion. A trial of ranitidine is an appropriate first step in management.

Term lengths

Previable: 22-25w Before 22 weeks no resuscitation 23-25 discuss risks and benefits, decision to resuscitate on case by case After 25w always resuscitate Preterm 25-36 Postterm >42

greatest predisposing factor for placenta previa in this pt?

Previous C-section

Preterm birth prevention

Pts with *short cervices*: *vaginal progesterone*- maintains uterine quiescence. Pts with *hx of PL* receive *IM progesterone starting 2 tri*mester & undergo *serial TVUS*. if TVUS reveals short cervix *cerclage* may be indicated

pyelonephritis in pregnancy

Pyelonephritis during pregnancy is a *leading cause of preterm labor*, which puts the baby at high risk for serious complications and even death.

Prenatal vitamins

Recommended to initiate prenatal kits containing folic acid 3 months prior to conception

PID complicated by perihepatitis (Fitz-Hugh-Curtis disease)

Right upper quadrant pain in addition to classic PID symptoms (fever, lower abd pain)

Hyperemesis Gravidarum HG

Risk factors: Multifetal gestation, Hydatiform Mole, Hx of HG *>5% loss of pre-pregnancy weight, dehydration, orthostatic hypotension Labs: ketonuria, hypochloremic M Alkalosis, hypokalemia, low Mg, low Ca

Placental abruption

Risk: maternal HTN, preeclampsia/eclampsia; abd trauma; cocaine/tobacco; prior placental abruption. Signs: hypertonic, tender uterus. At risk for *DIC & hypovolemic shock* management: aggressive fluid resuscitation with crystalloids & pt should be placed on *left lateral decubitus position* to *displace uterus off the aortocaval vessels* & maximize CO

Preterm prelabor rupture of membranes {PPROM}

Rupture *before 30 weeks* Risks: prior PPROM, conditions that *overdistend the membranes* (polyhydramnios); conditions that *inflame or weaken membrane* (BV, gonorrhea, asymptomatic bacteruria, antepartum bleeding) Management: <34 weeks- reassuring: latency antibiotics, corticosteroids <34 weeks- nonreassuring: delivery >34 weeks: delivery

secondary amenorrhea

Secondary amenorrhea is defined as at least** *three months without menses* in a woman who has passed menarche. Despite the fact that she denies having sexual intercourse, the most important first step in the evaluation of secondary amenorrhea is to rule out pregnancy. Adolescents in particular might be unwilling to share details of their sexual activity if they fear they might be punished, or in cases of sexual abuse. It is always important to talk to the adolescent privately, which was not done here. If the pregnancy test is negative, then further work-up may be warranted

cervical mucus (marks ovulation)

Secretion close to ovulation (late follicular phase) increase in quantity and perceived by pts as vaginal discharge. It's clear, elastic and thin, facilitates sperm transport into uterus for conception After ovulation the mucus becomes thick and less hospitable to sperm Vs. Cervical mucus plug- barrier to ascending infection during pregnancy, brown red or yellow thick mucus she'd before or during pregnancy

Granulosa cell tumor (ovarian)

Sex-cord-stromal tumor Secrete *estradiol & Inhibin* Juvenile-->precocious puberty Adult--> breast tenderness, AUB, postmenopausal bleeding. *Call-exner bodies (rosette pattern)*( Management: *Endometrial biopsy* (endometrial cancer) surgery (tumor stating)

Syphilis- treponema pallidum (chancre)

Single, indurated, well-circumscribed ulcer with clean base, non exudative

Bartholin duct cyst

Soft, mobile, well circumscribed masses at the base of the labia majora and are usually asymptomatic [typically at 4 and 8 o'clock position] gland typically drain into vulvar vestibule @4/8 to provide lubrication. Tx: Asx --> observation & expectant management Symptomatic --> Incision & drainage + Word catheter placement to reduce risk of recurrence

Ladin sign

Softening of the midline of the uterus - 6weeks

ectopic pregnancy management

Stable: methotrexate Unstable/ruptured: Surgery (salpingostomy or salpingectomy) unstable- acute abd d/t hemoperitoneum from ruptured EP. transvaginal US first line imaging for confirming location of gestational sac. Emergency surgical exploration is required in pt w/ hemoperitoneum & unstable vital signs Diagnose with TVUS & + pregnancy test bHCG risk factors: PID Levonorgestrel IUD IVF Previous EP (strongest risk factor)

Virchow's triad

Stasis, hypercoagulability, endothelial damage

Urethrocele may lead to _________ Incontinence

Stress incontinence

more common in vacuum-assisted vaginal deliveries than in forceps-assisted vaginal deliveries_________________

Subgaleal hemorrhage is a rare but catastrophic complication of vacuum-assisted vaginal delivery. Subgaleal hemorrhage occurs due to shearing forces between the layers of the scalp, and leads to massive bleeding from the veins which connect the venous sinuses to the superficial veins of the scalp. These veins pass between the aponeurosis and the periosteum of the skull. The loose connective tissue in the subgaleal space allows the scalp to move over the skull.

Pregnancy Risks d/t Hypertension

Superimposed preeclampsia Postpartum hemorrhage gestational diabetes abruptio placentae C-section fetal growth restriction perinatal mortality preterm delivery oligohydramnios

Early decelerations

Symmetric to contraction- nadir of deceleration corresponds to peak of contraction. Gradual (.30s from onset to nadir). Etiology: Fetal head compression Can be normal fetal tracing

Valproate

Valproate is an antiepileptic drug that is highly associated with the development of *neural tube defects*. For this reason, it is generally avoided in pregnancy. To mitigate the risk of neural tube defects, *high-dose folate supplementation* is recommended for pregnant women that are unable to discontinue valproate.

Obtain progesterone level one week before menses if suspect.. ovulatory dysfunction

The average menstrual cycle occurs every 28 to 35 days. This change in the patient's menstrual cycle, which previously was regular and now occurs every 35 to 40 days, should prompt evaluation of whether her cycles are ovulatory. Ovulatory dysfunction is a common cause of infertility, and it is able to be evaluated easily. Patients can confirm ovulation themselves through over the counter luteinizing hormone (LH) predictor kits, which identify the surge of LH at the start of the luteal phase of the menstrual cycle that subsequently stimulates ovulation. Ovulation can also be confirmed through evaluation of serum progesterone. After ovulation, the corpus luteum makes progesterone, thereby increasing serum progesterone levels. This test should be obtained one week prior to expected menses. A serum progesterone level above 3 ng/mL is suggestive of ovulation.

invasive breast cancer with axillary node metastases

The axillary nodes are typically the first place of lymphatic invasion in breast cancer. When metastasis is suspected in the axilla during clinical exam, a fine needle aspiration or core biopsy is performed to determine the surgical approach. If the biopsy is positive, an axillary node dissection should be done at the time of breast surgery. If the biopsy is negative, a sentinel lymph node biopsy (SLNB) should be done at the time of surgery

Ruptured corpus luteum cyst

The key here are the acuity of onset and where she is in her cycle. The severe onset of RLQ pain with light headedness is consistent with ruptured cyst, and the fact that she is in the luteal phase- post ovulation (24 days post period) points to a corpus luteum cyst. The cyst is fluid filled, so when it ruptures, the fluid goes into the abdominal cavity and annoys it, which is what's causing the symptoms

Causes of secondary amenorrhea

The most common cause of secondary amenorrhea is pregnancy, followed by hypothalamic dysfunction. Causes of hypothalamic-pituitary dysfunction include congenital GnRH deficiency (a cause of primary rather than secondary amenorrhea), systemic illness (such as type I diabetes or celiac disease), and nutritional deficiencies (as in anorexia or excessive exercise). While the patient's weight loss and change in diet may be the cause of her secondary amenorrhea, other causes must also be ruled out. This patient is not pregnant, so evaluation for thyroid dysfunction and hyperprolactinemia (e.g., due to a hypothalamic or pituitary mass) needs to be undertaken. Measurement of FSH should also be performed to to assess for premature ovarian failure (high FSH) versus dysfunction of the hypothalamus or pituitary (normal or low FSH). #1 B-HCG #2 FSH, TSH, Prolactin

cholestasis of pregnancy-- ursodeoxycholic acid

The most common symptom is intense pruritus, which may be generalized but often is worse at night and on the palms and soles. elevated serum bile acids, and elevated liver enzymes. Patients will also have elevated serum bile acids of over 10 micromol/L. Ursodeoxycholic acid, which reduces bile production, has shown to be effective in treating the condition. Although the maternal prognosis for cholestasis of pregnancy is good, with resolution after delivery, cholestasis of pregnancy carries significant risk for the fetus. Risks include intrauterine fetal demise, neonatal respiratory distress syndrome, and meconium stained amniotic fluid. Once the diagnosis of cholestasis is confirmed, the recommendation is for delivery at 36 weeks.

Congenital Cytomegalovirus

The most frequent viral cause of *non genetic deafness* in newborns is *ventriculomegaly* *periventricular calcification* *Intrahepatic calcification* *microcephaly* fetal growth restriction hydros fetalis

progestin challenge test results and meaning

The test is performed by administering progesterone orally in the form of medroxyprogesterone acetate (Provera), or intramuscularly. --If the patient has sufficient serum estradiol (greater than 50 pg/mL) then withdrawal bleeding should occur 2-7 days after the progestin is finished, indicating that the patient's amenorrhea is due to anovulation.*** --However, if no bleeding occurs after progesterone withdrawal, then the patient's amenorrhea is likely to be due to either a) **hypoestrogenism, b) hypothalamic-pituitary axis dysfunction, c) a nonreactive endometrium or d) a problem with the uterine outflow tract, such as cervical stenosis or uterine synechiae (Asherman's syndrome). bleed--> anovulation (no corpus luteum--> no progesterone) no bleed--> low estrogen

Which medication to use in pt with hx of myasthenia gravis that needs seizure prophylaxis (preeclampsia with severe features)?

Valproic acid Mg contraindicated as --> myasthenia crisis

theca lutein cyst

Theca-lutein cysts are multiple, bilateral and associated with choriocarcinoma and hydatidiform moles. Dermoid cysts are cystic teratomas. Follicular cysts are associated with hyperestrinism (increased estrogen) and endometrial hyperplasia. Corpus luteum cysts are associated with pregnancy and commonly regress on their own. Chocolate cysts are associated with endometriosis.

Preterm Labor evaluation

Transvaginal US measurement of cervical length in the 2nd trimester- *short cervical length* (<2cm or <2.5 in previous PL pt) strong predictor of preterm labor. Strongest risk factor for PL is prior PL in previous pregnancy

vulvar lichen sclerosus tx

Treatment first line: super potent topical corticosteroids (*clobetasol*) which decreases chronic inflammation

Stroke in Sickle cell disease

Treatment: *Exchange transfusion* (lowers % of sickled cells, increases oxygen carrying capacity, improves viscosity --> limiting further occlusion simple transfusion if exchange is unavailable TPA may be used in adults SCD pts but contraindicated in <18yo, Exchange transfusion is #1. IV heparin is contraindicated in stroke management -- risk if Intracranial hemorrhage Primary prevention: transcranial doppler screening during childhood Hydroxyuria +/- chronic transfusions Pathogenesis: Ischemic-- adhesion of sickled cells to vasculature Hemorrhagic-- Weakened cerebral vessels/ cerebral aneurysm rupture SCD increases the risk of ischemic stroke due to intimal hyperplasia and stenosis as well as occlusion of vasculature by adherent sickled cells

Uterine Rupture

Typically in pts with prior uterine surgery (C/S)-- uterine rupture the scar of the prior C/S. presents with *focal, intense abdominal pain* prior to rupture that is *relieved by rupture* but resumes shortly in a diffuse distribution. Signs: hyperventilation, agitation, *tachycardia, bleeding* Presenting fetal part may retract (*loss of fetal station*): pathognomic of rupture.

fetal growth restriction

US estimated fetal weight <10 percentile Symmetric: global growth lag. small head -chromosomal abnormalities or congenital infections. onset 1st trimester Asymmetric: Head sparing growth lag. --- Uteroplacental insufficiency, maternal malnutrition onset 2/3 trimester evaluation at delivery- histopathologic examination of the placenta to assess etiology

Congenital toxoplasmosis

US: b/l ventriculomegaly, diffuse intracranial calcifications. clinical features: chorioretinitis, hydrocephalus, seizures, intellectual disability, sensorineural hearing loss Diagnosis: mom- serology, fetus-amniotic fluid PCR maternal infection can be asymptomatic, or maculopapular rash that spontaneously resolves in days.

urge incontinence tx

Urge incontinence is treated with bladder training and medications. Anticholinergics, such as *oxybutynin and *tolterodine, are used to relax the detrusor muscle, thereby increasing bladder capacity and decreasing the sudden detrusor muscle contractions which trigger episodes of urge incontinence. Anticholinergics inhibit activation of M receptors leading to decreased muscle contraction.

Management of Hydatidiform Mole

Uterine evacuation via *suction curettage* Surveillance for the development of Gestational trophoblastic neoplasia (GTN) B-hCG levels are followed *weekly* until undetectable Plateau or increase in B-hCG level is diagnostic of GTN --> *Once undetectable* --> *monthly monitoring for 6 months* Contraception for at least 6 months!!!

Inevitable abortion

Vag bleeding, dilated os, products of conception may be seen or felt at or above cervical os

Menopause vs *hyper*thyroidsm

Vasomotor symptoms *(hot flashes), insomnia & irregular menses* consistent with both. have overlapping clinical manifestations & both are common in women 40-50. Mesure serum TSH and FSH level to confirm diagnosis. Menopausal transition & initial symptoms may begin few years before >45yo~

Rectus abdominis diastasis

Weakening of the linea alba, fascia that lies between rectus abdominis muscles. Results in non tender midline mass. No associated fasciae defects, no pain, observation and reassurance Risk factors: Chronic abd stretching- pregnancy, multiparity Surgical weakening- c sections Increased abd pressure- constipation

Asthma in pregnancy

While the ABG values would not be significant for impending respiratory failure in a normal patient, in a pregnant patient an *increasing PCO2* should alert the physician of *decreased respiratory drive* and possible need for an advanced airway placement. Patients with asthma that become pregnant will experience one of three outcomes: about 1/3 of patients will see an improvement in their asthma, 1/3 will stay the same, and 1/3 will get worse. Because of the respiratory changes that occur during pregnancy, the mother may not tolerate exacerbations as well. This patient is experiencing an acute exacerbation. *Stopping inhaled corticosteroids is seen as a risk factor for increased possibility of acute exacerbations*. In pregnancy, women are expected to have respiratory alkalosis as their tidal volume and respiratory rate both increase. This decrease in CO2 levels increases the CO2 gradient between the mother and fetus, which improves oxygen delivery to the fetus and CO2 removal. Therefore *CO2 should be low on arterial blood gas (ABG) normally, and an increase in PCO2 should be seen as an ominous sign of respiratory failure*.

Physiologic leukorrhea

White, odorless cervical discharge composed of cervical mucus, normal vag flora, and vag squamous epithelium. Increasing amounts of normal discharge typically occur mid cycle without manifestations of infection

Kallmann syndrome

X-linked, hypogonadotropic hypogonadism with anosmia. Pt has delayed puberty, and low/absent FSH/LH

The initial laboratory evaluation of a patient with primary or secondary amenorrhea consists of

a *pregnancy test* (Beta-human Chorionic Gonadotropin assay), as pregnancy is an easy diagnosis to exclude. primary amenorrhea, defined as absence of menses in the presence of normal secondary sexual characteristics by age 15, or absence of menses and secondary sexual characteristics (such as breast development) by age 13. Primary amenorrhea can be caused by anatomical abnormalities (such as Mullerian agenesis with an absent vagina or uterus, or a vaginal septum), genetic abnormalities (such as complete androgen insensitivity or Turner's syndrome), ovarian failure, or hypothalamic-pituitary dysfunction (due either to anorexia or hypopituitarism), polycystic ovarian syndrome, or physiological delay of puberty. #1-- *B-HCG* #2-- *FSH, TSH, Prolactin*

Pseudocyesis (false pregnancy)

a condition in which a female believes she is pregnant and shows some signs and symptoms of pregnancy even though she is not pregnant. (thin endometrial stripe, negative urine pregnancy test excludes pregnancy). likely d/t somatization of stress affecting H-P-Ovarian axis

Ovarian hyperstimulation syndrome

a syndrome resulting from *hyperstimulation of the ovaries by fertility drugs*, abnormal result to ovulation induction (clomiphene) caused by *overexpression of VEGF*; results in the *development of bilaterally enlarged cystic ovaries* with *increased vascular permeability* (inc doppler flow) which *causes 3rd spacing* (ascites, PE)

Stretching of the round ligament

abdominopelvic pain secondary to rapid expansion of the uterus, causing stretching or irritation of the uterine ligaments. The most commonly implicated ligament is the round ligament, which attaches to the uterine fundus and travels through the inguinal canal to attach distally to the labia majora. Pathogenesis is thought to be due to spasm of the ligament itself, or irritation of the nerves surrounding the ligaments. Other rarer causes involve other pathologies involving the ligament, including leiomyomas, endometriosis, and varicosities. Round ligament pain is a diagnosis of exclusion, and commonly occurs in pregnant patients late in the second trimester or early in the third trimester. Patients commonly present with right-sided, intermittent abdominopelvic pain with radiation to the groin, which is exacerbated with physical exercise and sudden positional changes. The pain is often self-limited and can be treated symptomatically

Variable decelerations

abrupt decrease in FHR (30s from onset to nadir at a HR of >/=15/min below the baseline & rapidly returns to baseline Etiology: Cord compression Cord prolapse Oligohydramnios

primary ovarian insufficiency (POI)

accelerated ovarian follicle depletion in women age <40, resulting in secondary amenorrhea, elevated FSH, & low estrogen levels. risk factors: FMR1 gene premutation for fragile X syndrome Turner syndrome (45, XO) Autoimmune oophoritis anticancer drugs pelvic radiation galactosemia

Vagina pH

acidic 3.8-4.5

Lactate dehydrogenase secreting germ cell tumor- dysgerminoma

adnexal mass, secrete *hCG, estrogen, LDH* Dysgerminoma is a type of *germ cell tumor* and is a *malignant* mass. These tumors usually occur in *young women* (teens and twenties); they are the female equivalent of seminomas.

bone mineral density (BMD) screening

all *women 65 and older* (or postmenopausal if risk factors present)

complete abortion

all products of conception are expelled through cervical os at <20weeks gestation. the cervix then closes and pain and bleeding subside. US reveals empty uterus. Risks: tobacco, alcohol, cocaine

Management of anovulatory cycles

anovulatory cycles --> have to allow regular shedding of the endometrium to prevent hyperplasia and possible carcinoma. with either *combined OCPs* or *monthly progesterone*

Craniopharyngiomas

are tumors arising from Rathke's pouch remnants in the anterior pituitary. They are characteristically solid, cystic and calcified. They often present during childhood with mass and visual defects . invade the sella turcica and neighboring structures. While craniopharyngiomas are more common in children, they do occur in adults as well. Adamantinomatous craniopharyngiomas are more common in children, while papillary craniopharyngiomas in adults

Letrozole

aromatase inhibitor DOC for PCOS- ovulation induction for fertilization (over clomiphene)

Acute appendicitis in pregnancy

atypical presentation of pain in right mid to upper quadrant pain or right flank pain. Intraabdominal inflammation & peritonitis, uterine irritability & contractions, fetal tachycardia (due to maternal fever). often a delayed diagnosis requires immediate surgery.

acute appendicitis in pregnancy

atypical presentation: pain mid to upper quadrant or right flank. during pregnancy the appendix undergoes cephalic displacement by the gravid uterus, often have delayed diagnosis, requires immediate surgery

Most serious complication of Bartholin gland abscess + cellulitis spreading is..

bartholin gland abscess plus cellulitis-- The worry about cellulitis in this area is always *Fournier gangrene* aka *necrotizing fasciitis* of the private parts.

endometrial cells on pap (appearance & implication)

benign appearing endometrial cells sample in postmenopausal women, pre- w/ abnormal uterine bleeding, or risk for endometrial hyperplasia. Atypical glandular cells: check on women age >/=35y or at risk for endometrial hyperplasia. Atypical glandular cells, favor neoplastic: check on all women.

Adenomyosis

benign invasive *growth of the endometrium into myometrium*. May cause *heavy, painful menstrual bleeding* d/t cyclic shedding of the endometrium within the myometrium. also present with chronic pelvic pain, *boggy, tender uterus*; ***induces myometrium hypertrophy --> symmetrically enlarged uterus*.

HG treatment

best initial therapy: diet modification, avoid triggers acupuncture, ginger, vit B6 Drugs: 1st: antihistamines doxylamine, diphenhydramine. Next, dopamine 2R antagonists: metoclopramide Last: serotonin 3R antagonist: ondansetron

CA-125 (cancer antigen-125 tumor marker)

biomarker for epithelial ovarian cancer. elevations caused by common gyn conditions (leiomyomata, endometriosis) that are more likely present in premenopausal pts; therefore *specificity* is much greater in *POSTMENOPAUSAL pts.* CA-125 measured in conjunction with pelvic US to categorize ovarian mass as malignant or benign . Also used to monitor recurrence of a proven malignancy after treatment.

McCune-Albright syndrome (mosaic G-protein signaling mutation)

triad: cafe au last spots, polyostotic fibrous dysplasia, autonomous endocrine hyperfuntion- most common gonadotropin-independent precocious puberty

Lynch Syndrome (HNPCC)

breast cancer is NOT associated with Lynch syndrome. To remember the Lynch-associated cancers, remember: *Lynch GOES to the PUB in a CAB*. Gastric, Ovarian, Endometrial, Small bowel; Pancreas, Ureter, Brain; Colorectal, Adenoma (sebaceous), Biliary.

Ovarian hyperthecosis

cause of virilization in postmenopausal women-> inc theca cells in ovaries--> high testosterone production. The inc in testosterone causes inc in peripheral production of estrogen --> low/normal LH & FSH levels signs of insulin resistance (hyperglycemia, acanthosis nigricans). US: *solid* appearing enlarged ovaries rather than multiple cysts (PCOS) d/t b/l increase in ovarian stroma.

AFLP

causes hepatic inflammation, fulminant liver failure (scleral icterus, hyperbilirubinemia, *profound hypoglycemia*). as AFLP *progresses develop multi organ system failure*, including *DIC* & *acute kidney injury*. As the mother decompensates, the *placenta hypoperfuses--> fetal hypoxemia, acidosis & death*. high maternal & fetal mortality rates ** Management is maternal stabilization & *immediate delivery*

Wernicke Encephalopathy

causes: chronic alcoholism, malnutrition (anorexia nervosa), *Hyperemesis gravidarum* Thiamine deficiency (Tx: *IV thiamine followed by glucose infusion*) Encephalopathy (altered mental status), nystagmus, gait ataxia Triad: *Confusion, Ataxia, Nystagmus -- CAN* Pts with HG typically have: hypochloremic metabolic alkalosis, hypokalemia, hypoglycemia, elevated serum transaminases

Broad-spectrum Polymicrobial coverage for PID

cefoxitin + doxycycline

Active Phase arrest

cervix unchanged despite adequate contractions (200MV in 10mins) for 4hrs. (normal 1cm every 2hrs). OR no cervical changes 6hrs with inadequate contraction. most likely due to late term gestation---> cephalopelvic disproportion/macrosomia. Next step is C-section because no further cervical change is expected & continuing to wait increases maternal-fetal morbidity (IAI, fetal hypoxemia)

vulvar lichen sclerosus

chronic inflammatory disease, common in postmenopausal women, particularly those with autoimmune disease (T1 DM). vulva thins, white areas-- itchy, burning, thick white vulvar plaques-- loss of labio minor and clitoral hood retraction. can cause dyspareunia and urinary simps. Dx: vulvar punch biopsy to confirm diagnosis

Acute cervicitis

commonly caused by *chlamydia & gonorrhea* Abnormal vag discharge-mucupurulent cervical discharge- & postcoital bleeding due to contact irritation-*friable cervix* that bleeds- gold standard is NAAT. Light microscopy not helpful, no organisms are visualized.

Uteroplacental insufficiency

d/t increased placental vascular resistance in late term pregnancies (>/=41w). decreased placental function result in intermittent fetal hypoxemia. on non stress test intermittent hypoxemia presents as late decelerations that gradually nadir after contraction peak. Progressive placenta dysfunction --> chronic fetal hypoxemia (uteroplacental insufficiency) causing CNS suppression & possible fetal demise. To prevent CNS suppression, blood is preferentially distributed to the brain instead pf periphery resulting in decreased fetal activity (movement, breathing, muscle tone). in the kidneys , decreased renal perfusion and urine production result in oligohydramnios. Late decels

human placental lactogen (hPL)

decreases maternal fatty acid stores and increases maternal serum glucose in order to provide adequate glucose reaching the placenta. The actions of hPL result in phsiologic insulin resistance in the latter half of pregnancy (gestational diabetes happens this way)

Fibrocystic breast disease (FBD)

disorder commonly seen in women of childbearing age that results in tender swollen breasts. FBD is most commonly seen with *hormonal changes during a woman's menstrual cycle* and tends to *improve towards the completion* of their menstrual cycle. On examination, patient's breasts are often *tender* to touch and can present with *several small tender nodules* throughout their breast tissue. These nodules are actually *inflamed swollen breast lobules* that results *from a spike in estrogen* levels during the menstrual cycle. Subtypes: 1. histology shows increased acini and intralobular fibrosis, which is indicative of Fibrocystic change, *sclerosing adenosis subtype*. 2. *Fibrosis* shows hyperplasia of the breast stroma. 3. *Cystic* shows cysts filled with fluid, which may appear blue when seen through the cyst wall (blue dome cyst). 4. *Epithelial hyperplasia* shows increased number of epithelial cell layers in terminal duct lobule.

Genitourinary syndrome of menopause (Atrophic Vaginitis)

due to estrogen deficiency results in: decreased collagen, elasticity & BF in the *bladder trigone & urethra* result in urogenital atrophy --inducing *urgency incontinence* other symsp: dysuria, urgency incontinence, recurrent UTIs.

Vaginal squamous cell carcinoma

due to persistent infection with HPV high risk 16/18 chronic tobacco use decreases the normal immune response, which allows for persistent HPV infection & squamous cell metaplastic changes

Braxton Hicks contractions

during 3rd tri. sporadic & do NOT cause cervical dilation. continued Braxton Hicks contractions means you should check the cervix. Preterm labor opens cervix, BH doesn't.

Parvovirus B19

during pregnancy can have devastating fetal consequences due to *viral cytotoxicity of fetal erythrocyte precursors* with increasingly *severe fetal anemia*, Fetal heart tries to compensate for hypoxemia by inc CO--> HOFHF develops & generalized skin edema. Causes slapped cheeks in children

Clomiphene

estrogen receptor antagonist Clomiphene is a type of selective estrogen receptor modulator (SERM) that functions by binding to estrogen receptors present in the hypothalamus and competing with estrogen.

effectiveness of contraceptives

etonogestrel implant is the most effective at preventing pregnancy, with a failure rate of 0.05%, followed closely by the levonorgestrel-containing IUD with a failure rate of 0.2%.

Complications of inappropriate pregnancy weight gain

excessive weight gain: gestational diabetes, fetal macrosomia, C-section Inadequate weight gain: fetal growth restriction, preterm delivery

Granuloma Inguinale- Klebsiella granulomatis (donovanosis)

extensive & progressive ulcerative lesions w/o lymphadenopathy. Base may have granulation-like tissue. Painless papule beefy red ulcer Deeply staining g(-) intracytoplasmic cysts (Donovan bodies)

Indications for endometrial biopsy in women <45yo with AUB:

failed medical management - OCPs persistent >6months AUB obesity Tamoxifen therapy

Shoulder Dystocia

failure of obstetric maneuvers to deliver fetal shoulders. Risk factors: fetal macrosomia, maternal obesity, excessive pregnancy weight gain, gestational diabetes, post-term pregnancy. Warning signs: protracted labor, retraction of fetal head into the perineum after delivery (turtle sign)

PCOS diagnosis test

fasting lipid panel American College of Obstetrics and Gynecology recommends screening for dyslipidemia with a fasting lipid panel at the time of diagnosis with PCOS.

Sinusoidal fetal heart tracing

fetal anemia ex: fetal blood loss

S. aureus Toxic Shock Syndrome TSS

fever, hypotension, macular rash involving palms and soles, HA, N/V, diarrhea. tampons, nasal packing. release of TSS toxin-1, an exotoxin that acts as a super antigen -->shock & multi organ failure.

Postpartum thyroiditis

first 6 months. brief hyperthyroid phase (release of preformed thyroid hormone) subsequent hypothyroid phase, Inc TSH, low free T4. elevated anti-TPO autoantibodies. Fatigue & irritability. other findings: hypercholesterolemia, and hyponatremia <136 self limited, pts return to euthyroid state over several months.

Diabetic nephropathy

proteinuria (>300mg/day; 1+ protein) PRIOR to 20weeks gestation in onset of DM. Increase risk for acceleration of their renal disease during pregnancy (worsening albuminuria, elevated creatinine) HTN common complication of diabetic nephropathy d/t excess Na retention & RAS activation. During normal pregnancy inc GFR & dec creatinine

Shoulder dystocia complications

fractured clavicle fractured humerus Erb-Duchenne palsy; waiter's tip- extended elbow, pronated forearm, flexed wrist & fingers Klumpke palsy: :claw hand" extended wrist, hyperextended MC, flexed IP joints, absent grasp reflex, Horner's syndrome (ptosis, mitosis) Perinatal asphyxia: varies depending on duration of hypoxia Perinatal asphyxia

RhoGAM IM

given @28w & within 72h from delivery Used to prevent an immune response to Rh positive blood in people with an Rh negative blood type

Anovulatory Cycles

heavy *irregular menstrual bleeding* due to immature HPO axis. In ovulatory cycles corpus luteum produces progesterone after ovulation which differentiates the proliferative endometrium into secretory--> as corpus luteum degenerates, the decrease in progesterone leads to normal menses through decrease in endometrial blood supply & shedding of the lining. Anovulatory cycles do not produce progesterone (no corps luteum develops)--> no differentiation into secretory endometrium. Unopposed estrogen stimulation results in uncontrolled proliferation of the endometrium. bleeding occurs when endometrial lining becomes too thickened & unstable. *Progesterone treatment* helps *stabilize uncontrolled proliferation*.

B-HCG (Beta-Human Chorionic Gonadotropin)

hormone secreted by the syncytiotrophoblast & is mainly responsible for the preservation of the corpus luteum in early pregnancy- in order to maintain progesterone secretion until the placenta is able to produce it on its own. Normal values doubles every two days for the first 4 weeks; at 10 weeks the b-HCG peaks and levels drop in 2nd trimester & increase slowly in 3rd trimester Best initial test for pregnancy. serum & urine US used to confirm an intrauterine pregnancy

Thrombosis to which artery is most likely to cause fetal demise in pregnant mom with factor V Leiden mutation

hypercoagulablity is something intrinsic to the mother and doesn't directly transfer to the fetus. The **uteroplacental artery** directly interacts with mother's blood and, therefore, it seems to be more vulnerable for thrombosis than the umbilical cord.

Management of PPROM

if diagnosed <34w is expectant. admin corticosteroids & a course of prophylactic Abx to prolong pregnancy and reduce complications. >34w deliver. **in pts with overt signs of IAI (fever, fetal tachycardia) delivery is indicated to decrease maternal & neonatal mortality.

Exclusion criteria for methotrexate

immunodeficiency (methotrexate is immunosuppressive) noncompliant patients liver disease (it can cause hepatotoxicity) *3.5 cm or larger ectopic* fetal heartbeat present (medical won't work) breastfeeding coexisting viable, heterotopic pregnancy

Intrahepatic cholestasis of pregnancy .. develops in _____ trimester?

in 3rd trimester. Generalized pruritus thats worse on hands & feet. No assoc rash, RUQ pain Inc total *bile acids >10umol/L* Inc transaminases +/- inc total & direct bilirubin Risks: Intrauterine fetal demise Preterm delivery Meconium stained AF NRDS Manage: Ursodeoxycholic acid, Antihistamines, *delivery at 37 weeks*

Younger woman have

increased cervical cell vulnerability to infection (STDs)

Operative Vaginal Deliveries (vacuum/forceps)

indicated for protracted 2nd stage of labor and FHR tracing abnormalities. Risk of fetal injuries & maternal complication- genital tract laceration (vag, cervix, perineum), rectal spinchter injury, UT injury-- PPH (postpartum hemorrhage)

Operative vaginal delivery (vacuum/ forceps)

indications: FHR abnormalities, protracted 2nd stage of labor, maternal contraindications for pushing. Fetal complications: laceration, cephalohematoma, facial nerve palsy, intracranial hemorrhage, shoulder dystocia Maternal complications: genitourinary tract injury, urinary retention, hemorrhage.

Decreased ovarian reserve

infertility in women with regular menstrual cycles due to diminished oocyte number & quality >35yo. Regular menstrual periods still occur due to continuing ovulation but decidability decreases due to diminished oocyte quality. day 3 (early follicular phase) FSH testing performed to asses ovarian function.

Down Syndrome

intellectual disability, Aat facies, prominentepicanthal folds, single palmar crease, incurved 5th finger, gap between 1st 2 toes, duodenal atresia, llirschsprung disease, congenital heart disease (eg, atrioventricular septa! defect), Brushfield spots. Associated with early-onset Alzheimer disease (chromosome 21 codes for amyloid precursor protein) and inc risk ofALL and AML. First-trimester ultrasound commonly shows inc nuchal translucency and hypoplastic nasal bone. Markers for Down syndrome are: High b-hCG and inhibin A; Low AFP and estriol (quad screen) The 5-As of Down syndrome: • Advanced maternal age • Atresia (duodenal) • Atrioventricular septal defect • Alzheimer disease (early onset) • AML/ALL

active phase protraction

is <1cm dilation in 2 hrs during the active phase of labor (6-10cm cervical dilation). cephalopelvic disproportion is common cause of labor protraction, also inadequate contractions, maternal obesity, & fetal malposition (occiput posterior)

Lichen simplex chronicus

is a chronic skin condition caused by a trigger, such as an irritant or infection, that causes pruritus, which leads to scratching. The scratching leads to skin damage which, in turn, leads to further itching. This itch-scratch cycle continues and leads to thickening of the skin. This patient has pruritus which began after exposure to a trigger (a new scented body wash) and has persisted, along with evidence of skin thickening on exam.

Physiologic hydronephrosis of pregnancy

kidney enlargement occurs d/t increase maternal blood volume that requires increased renal filtration resulting in greater renal vasculature & interstitial tissue. Hydronephrosis begins the 1st tri as high progesterone cause ureters dilation & dec peristalsis. Hydronephrosis becomes more pronounced in the 2/3 tri as uterine enlargement compress ureters at the pelvic brim--> dilation of proximal ureters & bilateral hydronephrosis, R is more pronounced d/t dextrorotation of the uterus. its physiologic so no additional management required. common symptoms of pregnancy: urinary frequency, nocturne, round ligament pain (sharp groin pain).

Cell-free fetal DNA

less invasive. only screening, not diagnostic Maternal serum blood test that extracts fetal DNA from maternal circulation with a 98% detection rate for fetal Trisomy 13 Trisomy 18 and trisomy 21 Cannot be used for multiple gestation

uterine rupture risk factors

life-threatening, can lead to both *maternal and fetal demise*. Uterine rupture *commonly occurs during labor*, and is associated with: previous scarring of the uterus, either from a Caesarean section or other uterine surgery. Risk factors associated with uterine rupture involving an unscarred uterus include: blunt abdominal trauma multiple gestation pregnancy grand multiparity inappropriate oxytocin administration, and excessive fundal pressure during delivery. (labor induction) Presentation of uterine rupture includes sudden onset, intense abdominal pain, vaginal bleeding, failure to detect fetal heart tones, loss of fetal station, abnormal abdominal contour, and loss of uterine contractions. Diagnosis can be made on clinical findings, but radiologic testing can be used to confirm uterine rupture. Management of uterine rupture includes hemodynamic stabilization and *urgent delivery via caesarian section*

Levonorgestrel IUD

long acting, reversible contraceptive that prevents pregnancy by releasing progestin that creates a physical barrier by thickening cervical mucus & impairing implantation through decidualization of the endometrium. for up to 5 yrs. Side effects: *amenorrhea* (improves anemia & AUB)

Levonorgestrel containing IUD

long acting, reversible contraceptive- thickens cervical mucus & impairs implantation. 5 years Side effect: amenorrhea- improves anemia & AUB

Epithelial Ovarian Cancer

mainly in *postmenopausal women* or FHx of breast cancer (BRCA1 carrier). early simps: bloating, abd pain. *firm, non-mobile pelvic mass with nodularity.* Symptoms of *ascites* (SOB, decreased appetite, abd distension, dec bowel sounds) likely due to peritoneal spread of cancer. *Exploratory laparotomy* with ca resection & inspection of abd cavity for mets (surgical staging) is required.

Endodermal sinus (yolk sac) tumor

malignant tumor that mimics the yolk sac, and is the most common germ cell tumor in children, although it can also be found in older adults. Yolk sac tumors commonly have an elevated AFP. AFP can also be elevated in mixed germ cell tumors and hepatocellular carcinoma.

Screening for breast cancer

mammography initially at age 50 due to increasing risk of breast cancer with age, other risks: nulliparity, obesity HRT (increase estrogen exposure). Breastfeeding is protective. RRR relative risk reduction.

Oligohydramnios

marker for placental insufficiency, requires immediate delivery oligohydramnios, defined as an amniotic fluid index of less than or equal to 5 cm, or the single deepest pocket of amniotic fluid measuring less than 2 cm.

Chloasma/Melasma

mask of pregnancy- 16 weeks

Intraductal papilloma

mass that is commonly *palpated just behind the areola* and is the most common reason for *unilateral bloody discharge* of the breast. These masses are not malignant but are *premalignant***

hyperemesis gravidarum

metabolic alkalosis d/t significant volume depletion & loss of gastric acid. Morning sickness *caused by an increase in estrogen, progesterone, & HCG* made by the placenta

TTTS Twin-twin transfusion syndrome

monochorionic twins (1 placenta) at risk. can result in HF & fetal mortality in both twins. Unbalanced arteriovenous anastomoses are present btw shared placentals. Donor twin: anemia--> renal failure, oligohydramnios, Low-output HF, fetal growth restriction. Recipient twin: polycythemia-->polyhydramnios, cardiomegaly, HOHF, & hydros fetalis

Malignant hyperthermia

mutation of calcium channel. triggered by anesthetics, succinylcholine, excessive heat. Manifestations: generalized rigidity, sinus tachy, hypercarbia resistant to inc minute ventilation, rhabdomyolisis, hyperkalemia, hyperthermia (late manifestation). Treat: respiratory/ventilatory support, cessation of causative anesthetic, dantrolene

missed abortion

no vag bleeding, closed os, no fetal cardiac activity or empty sac

Acute fatty liver of pregnancy

often asymptomatic, but may have nausea, malaise, headache abdominal pain. 50% also have PREECLAMPSIA and 60% will develop acute RENAL FAILURE. Biopsy will show microvesicular fat deposition in hepatocytes, but NO NECROSIS. Labs can show elevated PT and LFTs *3rd tri. RUQ pain, jaundice, elevated transaminases*. Signs of fulminant liver failure, including thrombocytopenia (<100K) & profound *hypoglycemia*)

Potter sequence (syndrome)

oligohydramnios-->compression of developing fetus-->limb deformities, facial anomalies (low-set ears, retrognathia), compression of chest lack of amniotic fluid aspiration into fetal lungs--->pulmonary hypoplasia (cause of death) POTTER sequence associated with: Pulmonary hypoplasia Oligohydramnios (trigger) Twisted face Twisted skin Extremity defects Renal failure (in utero)

KOH kills

only see pseudohyphae. On saline see clue cells, trichomonads..

cervical insufficiency

premature, painless, dilation of the cervix. may *cause 2nd trimester delivery*, vag spotting, pelvic pressure, & inc vag discharge. Cone biopsy (removal of portion of cervix) is a risk factor. pts may undergo *rescue cerclage*

nephrolithiasis

present with renal colic, hematuria, nausea, vomiting, dysuria, and urinary urgency. The pain in nephrolithiasis is commonly localized to the flanks, with radiation to the groin.

Multiple gestation risk for

preterm labor

lactational amenorrhea

prolactin inhibitory effects on production of GnRH--> dec LH/FSH by ant pituitary suppressing ovulation & menstruation Natural form of contraception for the first 6 months postpartum if mother is breastfeeding exclusively, after first 6 months, >50% women resume ovulation & another form of contraception should be considered

Ovarian vs adrenal tumors

ovarian androgen secreting tumors produce elevated testosterone (>150ng/dl) adrenal tumors produce elevated dehydroepiandrosterone levels (>700mcg/dl)

Ovarian torsion

ovarian mass, woman of reproductive age Risk: infertility treatment with ovulation induction Sudden onset unilateral pelvic pain, nausea & vomiting. US: adnexal mass with absent doppler flow to ovary Tx: Exploratory Laparoscopy with detorsion, ovarian cystectomy. Oophorectomy if necrosis or malignancy Laparoscopy can determine the extent of the tissue damage. The torsed tissue can be turned back into its correct position (detorsed). The cyst can also be removed and the ovary fixed to the pelvic sidewall (oophoropexy) laparoscopically to prevent recurrence. If staff and equipment for laparoscopy are not available, exploratory laparotomy is also a reasonable approach.

post partum hemorrhage

over 500mL of blood loss after a vaginal delivery or 1000mL or more after C/S divided into primary and secondary hemorrhage. Primary occurs within 24h of delivery & secondary (delayed) anywhere from 24h to up to 12 weeks postpartum

Biophysical Profile (BPP)

performed in pts at risk for uteroplacental insufficiency includes (5): 1. NST 2. US assessment of amniotic fluid index (*max vertical pocket >/=2*) 3. fetal breathing (1 or > lasting at least 30sec in 30m) 4. fetal movement (>3 in 30mins) 5. Fetal muscle tone (1 flexion and extension in 30m) Normal (8 or 10) exclude fetal hypoxia, abnormal BPP (</=4) suggests risk of fetal demise. *Max vertical pocket* normal values *2-8*

Rheumatic mitral stenosis in a pregnant woman

physiologic *increases in HR & BV* raise transmittal gradient & LAP, precipitating symptoms of fatigue, exercise intolerance, or dyspnea. *At risk of developing Atrial Fibrillation*, worsening *pulmonary edema* (cough, progressive dyspnea, orthopnea)

placenta previa

placenta covers cervix, presents as painless vaginal bleeding. diagnosed on US. during labor contractions or cervical manipulation can shear the placenta off the cervix resulting in massive maternal hemorrhage- therefore= C/S is indicated after 36-37weeks majority self resolve

OCPs can cause mild or overt HTN

possibly due to *estrogen mediated increase in hepatic angiotensionogen synthesis* or effects on RAS

Septic pelvic thrombophlebitis

postoperative or postpartum infected thrombosis of the deep pelvic or ovarian veins. Pt have persistent fever & unresponsive to antibiotics. treatment includes anticoagulation and antibiotics. risks: hyper coagulable state of pregnancy pelvic venous stasis & dilation endothelial damage from infection

HELLP Syndrome

potential manifestation of severe preeclampsia. Nausea/vomiting, RUQ and pain. Liver swelling with distension of the hepatic (Glisson's capsule), resulting in RUQ pain or epigastric pain. Lab: microangiopathic hemolytic anemia (anemia with indirect hyperbilirubnemia), elevated liver enzymes, Low platelet count Tx: delivery is warranted >/=34weeks or with deteriorating maternal or fetal status.

Pathophys of Pulmonary edema in preeclampsia/eclampsia

pre-eclamptic pts have generalized arterial vasospasm--> increased systemic vascular resistance & high cardiac afterload--> inc pull capillary P -- Pulm edema. decreased renal function & decreased serum albumin & endothelial damage also leaf to increased capillary permeability

postterm pregnancy

pregnancy at 42 w of gestation and beyond. Risk of: macrosomia-- prolonged labor & shoulder dystocia Dysmaturity syndrome with oligohydramnios secondary to poor placental function, passage of meconium (risk of meconium aspiration), loose dry skin, & neonates small for gestational age d/t placental insufficiency. Perinatal mortality also increased. Recommended induction of labor at 41w and beyond

Craniopharingioma

rare tumors that invade the sella turcica and neighboring structures. While craniopharyngiomas are more common in children, they do occur in adults as well. Adamantinomatous craniopharyngiomas are more common in children, while papillary craniopharyngiomas are more common in adults. **Headaches and amenorrhea are common symptoms of craniopharyngiomas in adults. *Endocrine abnormalities including amenorrhea are common in women with this disorder and are caused by decreased GnRh secretion.

Category 1 Fetal Heart Tracing

reassuring status

Antiphospholipid syndrome

recurrent pregnancy loss & TIA (sudden weakness, slurred speech). is an autoimmune disorder -- venous or arterial thrombosis due to membrane antiphospholipids antibodies. APD can occur alone or associated with SLE. Abs mediate hypercagulable state that may cause placental thrombosis.. require anticoagulation with heparin after acute thrombotic events during pregnancy, Pts require long term treatment with warfarin.

Zidovudine (AZT)

reduce perinatal HIV transmission, administered to neonate for *>/= 6 weeks*

treatment goals of PMS

relieve symptoms and improve daily functioning. For patients with *mild symptoms* that do not cause stress or negatively affect daily functioning, treatment can begin with *lifestyle measures* including regular *exercise and stress reduction techniques*. For patients with *moderate to severe symptoms* including socioeconomic dysfunction (i.e., missing days of school/work as in the patient above), first-line therapy consists of selective serotonin reuptake inhibitors (*SSRIs*), such as sertraline, fluoxetine, escitalopram, or citalopram. Second-line therapies include *oral contraceptives, GnRH agonists, and surgery* (i.e., hysterectomy) as a last resort.

cervical mucus

secretion close to ovulation (late follicular phase) increases in quantity & can be perceived as vaginal discharge. it is clear, elastic, thin, uncooked egg white. facilitates seen transport into the uterus for conception. After ovulation occurs the mucus becomes thick & less hospitable to sperm

pruritic urticarial papules and plaques of pregnancy (PUPPP)

self-limited condition that commonly presents in primigravid women during the peripartum period. The lesions in PUPPP initially present as pruritic, erythematous papules in the area of the abdominal striae, and can spread to the remainder of the torso and extremities. Areas that are not usually affected include the face, palms, and soles. Papules can coalesce to form plaques, and lesions can appear vesicular, target-like, or erythematous. This condition is not harmful to the patient or newborn but may be distressing and uncomfortable, as the pruritic lesions can affect sleep. PUPPP usually resolves within 1-2 weeks after delivery. Differential diagnoses can include scabies, erythema multiforme, and drug eruptions. Diagnosis can be made by history and physical examination. Tissue biopsy is not necessary for diagnosis, but may be performed if the diagnosis is unclear. Treatment involves symptomatic relief, and initial therapy includes moisturizing creams. Moderate to severe cases can be treated with topical corticosteroids.

chancre

single, indurated, well-circumscribed ulcer, clean base. superficial ulcer with a yellowish serous discharge that is a sign of syphilis treat: IM benzathine penicillin G

PPH uterine atony

soft (boggy) & enlarged uterus. risks: prolonged labor, induction of labor, operative vaginal delivery & fetal weight >4000g

Goodell's sign

softening of the cervix - 4 weeks

Congenital Zika Syndrome

ssRNA flavivirus transplacental transmission targets neural progenitor cells Severe microcephaly, craniofacial disproportion Neuro abnormality (spasticity, seizures) Ocular abnormalities calcifications, ventriculomegaly, cortical thinning travel to tropical mosquito infested regions: Aedes

*recurrent* uncomplicated cystitis

start *pharmacologic prophylaxis*!!! with either *daily or post-coital dosing*. Possible agents include nitrofurantoin, trimethoprim alone, trimethoprim/sulfamethoxazole, cephalexin, ciprofloxacin, fosfomycin, cefaclor, and norfloxacin.

round ligament of uterus

symptoms are most consistent with round ligament pain. The pain is localized to the lower uterus, exacerbated by movement, and improved with rest Contractions of preterm labor would be expected to cause discomfort over the entire uterus, and would be unaffected by activity. When this patient's pain comes, it lasts 3-5 minutes, which is much longer than a contraction would be expected to last.

Cell free DNA testing

takes blood sample of the pregnant person, which has a small amount of fetal DNA. from ***7 weeks first trimester., not approved for multiple gestations detect sex, routine prenatal screening for Rh factor & aneuploidy

Diethylstilbestrol

teratogen that can cause *clear cell adenocarcinoma of the *vagina and other genital tract defects.

thalidomide

teratogen that can cause limb defects including the absence of limbs (amelia) and phocomelia (flipper-like limbs).

atrophic vaginitis

thinning of the vagina and loss of moisture because of depletion of estrogen--> elevated vaginal *pH >/=5* d/t reduced lactobacilli activity. loss of epithelial elasticity

*Hb electrophoresis* to diagnose...

to diagnose *thalassemia* ---> hydros fetalis in thalassemia major

Symptomatic nephrolithiasis

typically occurs during 2/3 trimesters because pregnancy causes progesterone induced urinary stasis & increases urinary Ca excretion. Intermittent flank pain radiating to groin, hematuria US of the kidney & ureters because low risk of radiation exposure

Mixed urinary incontinence

urine loss with features of two or more types of incontinence. Initial evaluation--> voiding diary to classify the predominant type & determine optimal tx. generally require bladder training & pelvic floor muscle exercises.

Prolapsing leiomyoma uteri

uterine irregular enlargement. firm, smooth, round mass at the cervical os consistent with aborting aubmucous myoma. Fibroids arise from myometrium - heavy & prolonged menstrual bleeding. Expulsion causes labor-like pain due to mechanical cervical dilation by solid mass.

complete abortion

vag bleeding, closed os, products of conception completely expelled

Incomplete

vag bleeding, dilated os, some products of conception expelled & some remain

threatened abortion

vaginal bleeding, closed os, fetal cardiac activity

Uterine rupture signs

vaginal bleeding, intraabdominal bleeding (hypotension, tachycardia), late decelerations, loss of fetal station, palpable fetal parts on and exam, loss of intrauterine Pressure. Laparotomy for delivery & uterine repair.

vitiligo

white patches on the skin caused by the *"destruction of melanocytes"* associated with *autoimmune* disorders Tx: *corticosteroids* & phototherapy

HSV

without treatment most immunocompetent pts have spontaneous resolution of symptoms within a week. Many pts will experience disease recurrence (particularly first year after primary infection), then recurrence becomes less frequent. Acyclovir reduce symptom duration & frequency of recurrences but do not eliminate recurrences.