CS Unit 4

Menorrhagia

(hypermenorrhea)- excessive or prolonged menses (>80ml OR >7 days) occurring at normal intervals

Breast Mass Evaluation Imaging

*Mammogram* All women over 35 with discrete palpable mass *Ultrasound* Better in young women Distinguish solid from cystic mass *MRI* Screening in high risk Staging of breast Ca Evaluate for recurrence of breast Ca

STI Prevention

*Primary Prevention* Education *Secondary Prevention* Screening *Tertiary Prevention* Prevention of complications Prevention of transmission

DOCUMENTATION- Breast Masses

*Structure* Soft Mobile Firm Hard Tender Fixed Matted *Location* Right/Left breast Distance to areola Clock System (4 O'clock) Quadrant (Upper/Outer)

Gonorrhea - Clinical Manifestations

*Urethritis - male* *Incubation: 1-14 d (usually 2-5 d) *Sx: Dysuria and urethral discharge (5% asymptomatic) Complications *Urogenital infection - female* Endocervical canal primary site 70-90% also colonize urethra Incubation: unclear; sx usually in l0 d Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abdominal pain Complications Extra-genital infection mostly asymptomatic!!

Ovarian Neoplasm Classifications: Germ Cell

-Dysgerminoma -Endodermal sinus - Cystic Teratoma

Testicular Cancer

-Rare Most common is seminoma (less common is choriocarcinoma, etc.) Most commonly in young, Caucasion males (20-40).* It is also more common in men who: Have had abnormal testicle development * Have had an undescended testicle * Have a family history of the cancer* Symptoms include: Swelling* Masses in testicles or groin *** Rapidly enlarging, non painful mass in the testicle* Fastest growing cancers in the human body Diagnosis - Testicular exam* Ultrasound of the testicle** Most common method of diagnosis. CT* Serum markers: beta-HCG* Alpha-fetoprotein (AFP)*

Bi-Rads Classification of Mammo

0- Additional Imaging is Needed 1- Neg 2- Benign 3- Probably Benign- short interval follow up recommended 4- Suspicious Abnormality - biopsy should be considered 5- Highly suggestive of malignancy

von Willebrand's Disease Labs

1 Factor VII Antigen, Ristocetin (Functional Measure of VWF)= Reduced 2 Factor VIII Coagulant Acitivity= Reduced 3 Partial Thromboplastin Time (PTT)=Prolonged 4 Prothrombin Time (PT)= Unaffected 5 Bleeding Time= Prolonged 6 Collagen Binding Activity (Ability of VWF to bind to endothelium)= Decreased 7 Von Willebrand Antigen (Quantitative Measure of VWF)= Low

National Institutes of Health Chronic Prostatitis Workshop

1) Acute bacterial prostatitis is an acute infection of the prostate 2) Chronic bacterial prostatitis is a recurrent infection of the prostate 3) Chronic nonbacterial prostatitis /chronic pelvic pain syndrome (CPPS) includes: 3.1) Inflammatory CPPS = WBC's in semen, EPS, VB-3, Cult - 3.2) Noninflammatory CPPS = no WBC in semen, EPS, VB-3 (Prostatodynia) 4) Asymptomatic inflammatory prostatitis = no sx's but positive WBC'S semen and EPS

Each prior pregnancy should be reviewed in chronologic order and the following information recorded:

1. Date of pregnancy 2. Outcome of each pregnancy 3. Duration of gestation (recorded in weeks). The gestational age of every pregnancy is of importance—term, preterm, spontaneous or therapeutic abortion, for subsequent pregnancies. 4. Type of delivery (or method of terminating pregnancy). 5. Duration of labor (recorded in hours). 6. Type of anesthesia 7. Maternal complications 8. Newborn weight (in grams or pounds and ounces). 9. Fetal and neonatal complications

A 17 year old female presents with complaint of fatigue. Her menstrual history includes menarche at age 15, menses are regular at 28 days, she has 6 days of bleeding, and states she has to change her pad every 2 hours the first 3 days. 1. How would you describe her menstrual cycle? 2. What's on your differential diagnosis? 3. What history would you want to know? 4. What are important physical characteristics to note?

1. Menorrhagia

The cyclic changes in histophysiology of the endometrium can be divided into three stages:

1. Menstrual phase 2. Proliferative (estrogenic phase) 3. Secretory (progestational phase)

Benign Breast Disease

1. Non-Proliferative Breast Lesions 2. Proliferative Breast Lesions without Atypia 3. Atypical Hyperplasia

The LH surge drives 3 events in the ovary

1. Primary oocyte completes meiosos I and arrests in metaphase of meiosis II. Germinal vesicle breakdown (GVBD) occurs ~30hrs after LH surge and involves dissolution of nuclear membrane and interphase nuclear structure. 2. Wall of follicle and ovary at the stigma is broken down with release of cumulus-oocyte (ovulation) ~32-36 hrs after LH surge 3. Granulosa and thecal cells are restructured to form corpus luteum (CL). Involves direct vascularization of granulosa cells and their differentiation into estrogen and progesterone producing cells. Note the drop in estrogen for about 2 days while this occurs.

Operative Delivery: Four Indications

1. Prolonged second stage of labor. --In nulliparous women, this is defined as lack of continuing progress for 2 hours without regional anesthesia or 3 hours with regional anesthesia. --In multiparous women, it is defined as lack of continuing progress for 1 hour without regional anesthesia or 2 hours with regional anesthesia. 2. Suspicion of immediate or impending fetal compromise as defined by Category III fetal heart rate patterns 3. To stabilize the after-coming head during a breech delivery 4. To shorten the second stage of labor for maternal benefit. Maternal conditions such as hypertension, cardiac disorders, or pulmonary disease, in which strenuous pushing in the second stage of labor is considered hazardous, may be indications for forceps delivery. Epidural analgesia, which also decreases strenuous pushing during the second stage of labor, may also be recommended for this purpose. Before performing a forceps-assisted vaginal delivery, appropriate consent from the patient regarding potential risks and benefits should be obtained. Anesthesia must be adequate via either pudendal nerve block with local infiltration (for outlet forceps only) or regional anesthesia. The bladder should be emptied to prevent damage to that structure and to provide more room to facilitate delivery. If progress of the fetal head is not obtained with appropriate traction, the procedure should be abandoned (failed forceps) in favor of a cesarean delivery.

Nine Key Questions to ask when evaluating an adnexal mass

1. What is the size of the lesion? 2. Is the mass solid? 3. Is it a simple or complex cyst? 4. Is the cyst loculated? 5. Are papillary excrescences present? 6. Are there echo-dense foci? 7. Is there echogenicity of interior fluid? 8. Is measurable fluid in the cul-de-sac? 9. How does the mass change over time?

Four indications account for 90% of the marked increase in cesarean deliveries over the past 40 years:

1. dystocia (30%) 2. repeat cesarean (25-30%) 3. breech presentation (10-15%) 4. fetal distress (10-15%) An absolute indication for a cesarean delivery is a previous full-thickness, nontransverse incision through the myometrium

General anesthesia is employed for cesarean delivery in three situations:

1. there is extreme urgency and no preexisting epidural catheter 2. there is a contraindication to regional anesthesia 3. regional anesthesia has failed (1.7% incidence)

Female routine diagnostic eval

1.Pregnancy Test 2 PAP/Colpo any visible lesion 3 EMBx vs D+C/Hysteroscopy (Sampling in women over 45yrs with AUB or hx of unopposed Estrogen or Failed Medical Management) 4 Pelvic/Transvaginal Ultrasound 5 Saline Infusion Sonohystogram

Kleihauer-Betke Test

10% fetal hemoglobin cells to adult Hgb Fetal red cells = MBV X % fetal cells in KB newborn Hct MBV- maternal blood volume (about 5000 ml)

Pelvic Inflammatory Disease (PID)

10%-20% women with *GC develop PID In Europe and North America higher proportion of C. trachomatis CDC minimal criteria *Uterine tenderness, adnexal tenderness +/- cervical motion tenderness Other symptoms include endocervical discharge Fever lower abdominal pain *Complications* *Infertility 15%-24% with 1 episode PID secondary to gonorrhea or chlamydia 7X risk of *ectopic pregnancy 1 episode PID *chronic pelvic pain in 18%

A typical pregnancy lasts

280 days or 40 weeks, starting from the first day of a normal menstrual period.

Indications for administration of anti-(D) immune globulin

28wks gestation Spontaneous abortion, threatened abortion, induced abortion Eptopic pregnancy Invasive procedures: enetic aminocentesis; chorionic villus sampling; multi-fetal reduction; fetal blood sampling Hydatidiform mole Fetal death in the second or third trimester Blunt trauma to the abdomen Antepartum hemorrhage in the second or third trimester (eg, placenta previa or abruption) External cephalic version

Epidemiology of Endometrial Ca

36,000 new cases a year 7,350 deaths per year Average age 60 years Only 8% less than 45 years of age No Screening Test Usually Adenocarcinoma

HPV Percentages

40 % of females 20-29 are HPV (+) 80% lifetime likelihood of infection 90% of immunocompetent women will have a spontaneous resolution over a 2-year Only approximately 5% will have cytological detectable CIN

Acute Retroviral Syndrome

50% develop an acute mononucleosis like syndrome about 2-6 weeks after infection Fever, rash, lymphadenopathy, headache, arthralgias. Generally lasts 1-3 weeks. 10% with acute aseptic meningitis. Most will present with acute syndrome due to profound symptoms (many dismissed as the flu and no work up performed) Those at risk (by review of systems and risk factors, check p24 and HIV RNA)

HIV Asymptomatic stage

50% of untreated HIV develop AIDS within 10 years <10% are asymptomatic at 10 years Adolescents progress at a slower rate <30% develop AIDS at 10 years Route of transmission has no association 30-40% have generalized lymphadenopathy while asymptomatic Immune based thrombocytopenia (ITP) is common Mucocutaneous lesions may arise Recurrent oral/genital herpes, oral/vaginal candidiasis, polydermatomal Varicella zoster (shingles), oral hairy cell leukoplakia. Oral Ulcers in Acute HIV Infection

Direct Hernias

A direct inguinal hernia occurs due to a defect or weakness in the transversalis fascia area of the Hesselbachs triangle

Intrauterine Insemination

A semen specimen is washed to remove prostaglandins, bacteria and proteins. The sperm is then suspended in a small amount of medium Specimen is placed in a thin, flexible catheter and the catheter is advanced through the cervix into the uterine cavity Total motile sperm count of at least 1 million must be present

Vaginal delivery after C-sec

A trial of labor may be offered if one or two previous LTCDs have been performed The overall success rate of VBAC is approximately 70%,although it ranges from 60% (dystocia) to 90% (malpresentation

Postpartum Breast

AAP - Recommends breast feeding exclusively for 6 months and through 1st year WHO - Recommends breast feeding exclusively for 6 months and until at least 2 years of age La Leche League - http://www.lllusa.org

The First Prenatal Visit: Diagnostic Work-up

ABO and RH type: repeated at 28 weeks; Women who are Rh negative should receive RhO(D) immune globulin (RhO-GAM) at 28 weeks' gestation and postpartum, and at any point of care when sensitization may occur Syphilis Gonorrhea and Chlamydia HIV teting Rubella, Measles, TB, Varicella, Hepatitis B Glucose testing: for high risk individuals Group B testing

SCREENING-Self Breast Exam

ACOG Recommends Breast self awareness that can include SBE Recommends Against USPSTF WHO NCCN - breast awareness without self exam (National Comprehensive Cancer Network)

Recommendations: Mammogram Frequency

ACOG Yearly screening WHO 1-2 yrs for women 50-69yrs USPSTF Biennial Mammogram

SCREENING-Clinical Breast Exam

ACS Every 3 years from 20-39yrs Annually thereafter ACOG Every 1-3yrs from 20-39yrs Annually thereafter RECOMMENDS AGAINST WHO CTFPHC USPSTF (States no evidence to support)

Recommendations: Screening with MRI of the breast

ACS (Annual MRI) Known BRCA mutation carriers 1st degree relatives of known BRCA mutation carriers Women with a lifetime risk of Breast CA of 20 to 25% NCCN (Annual MRI) BRCA 1 or 2 mutation carriers Untested women with a first degree relative with a BRCA 1 or 2 mutation Lifetime risk 20-25% Radiation treatment to chest at 10 to 30yrs Li-Fraumeni Syndrome

TUMOR MARKERS for ENDODERMAL SINUS

AFP

Cervical Cancer Signs and Symptoms

Abnormal vaginal bleeding Postcoital bleeding Vaginal discharge Pelvic pain Leg swelling Urinary frequency Fistula formation - loss of urine or stool from the vagina

Confirming Pregnancy and Determining Viability

About 30-40% of all pregnant women will have some bleeding during early pregnancy (e.g., implantation bleeding), which may be mistaken for a period. The pregnancy test detects human chorionic gonadotropin (hCG) in the serum or the urine. It is important to differentiate a normal pregnancy from a nonviable or ectopic gestation. In the first 30 days of a normal gestation, the level of hCG doubles every 2.2 days The use of transvaginal ultrasonography has improved the accuracy of predicting viability in early pregnancies. The presence of a gestational sac of 8 mm (mean sac diameter) without a demonstrable yolk sac, 16 mm without a demonstrable embryo, or the absence of fetal cardiac motion in an embryo with a crown-rump length of greater than 5 mm indicates probable embryonic demise.

Abruptio Placentae

Abruptio placentae, or premature separation of the normally implanted placenta, complicates 0.5-1.5% of all pregnancies (1 in 120 births). Predisposing Factors and Pathophysiology The most common of these risk factors is maternal hypertension, either chronic or as a result of preeclampsia. The risk of recurrent abruption is 10% after one abruption and 25% after two. Placental separation is initiated by hemorrhage into the decidua basalis with formation of a decidual hematoma. The resulting separation of the decidua from the basal plate predisposes to further

Category III FHR tracings include either of the following:

Absent baseline FHR variability *and* any of the following: Recurrent late decelerations Recurrent variable decelerations Bradycardia Sinusoidal pattern

Hyperandrogenic Disorders

Adrenal Disorders Late-onset congenital adrenal hyperplasia Cushing syndrome Adrenal adenomas/carcinomas Ovarian Disorders PCOS Ovarian neoplasms

Gatroesophageal disorders associated with HIV

Advanced disease (CD4 <50) dysphagia (painful swallowing - primarily Candida esophagitis), diarrhea, and colitis common. May contribute to wasting syndrome. Nausea and vomiting most frequently from medications. Treat with antiemetic, Histamine 2 antagonists, Proton pump inhibitors (if no response to changes in medication regimen) Abnormal liver transaminases: Frequently medications but may be MAI, Hep B/C, CMV, acalculous cholecystitis, cholecystitis, cryptosporidia, or AIDS sclerosing cholangitis Diarrhea Many different infectious processes result Mild to profuse/watery/explosive Often no clear etiology found (HIV associated enteropathy vs. medication side effects) Check stool Ova & Parasite Especially Cryptosporidia and Isospora (most common parasitic GI infections in AIDS) Cultures Salmonella, Campylobacter, Yersinia frequent causes Clostridium difficile toxin (from frequent antibiotic use resulting in C. diff. infection If work up negative: endoscopy with biopsy for cryptosporidia, MAI, CMV infections or villous atrophy from HIV enteropathy

Asymptomatic Inflammatory Prostatitis

Antibiotics?? NSAIDS?? Check baseline PSA before treatment and if elevated, repeat after treatment.

Fetal Evaluation after Delivery

Apgar Score The Apgar scoring system has classically been used to assess the newborn's condition Fetal cord blood sampling: a more appropriate tool for defining asphyxia is assessment of the fetal and neonatal acid-base status. One reasonable protocol for umbilical cord blood pH and blood gas analysis is as follows: Doubly clamp a segment of umbilical cord immediately after birth in all preterm deliveries and in term deliveries where fetal distress is suspected, as well as in cases where the 1- and/or 5-minute Apgar score is low (<7). If a specimen cannot be obtained from the umbilical artery of the cord, obtain a specimen from an artery on the chorionic surface of the placenta.

von Willebrand's Disease Signs and treatment

Autosomal dominant Deficient or defective von Willebrand factor Effects platelet adhesion Signs and Symptoms Mild Epistaxis Gingival Bleeding Menorrhagia Bleeding after surgery or dental extraction Treatment Avoid ASA Desmopressin OCP Progesterone GnRH Agonisits Anti-Fibrinolytic (Lysteda - Tranexamic Acid) Correction of Anemia (blood products and iron)

TUMOR MARKERS for MALIGNANT GERM CELL TUMORS

B-HCG, LDH, AFP

TUMOR MARKERS for EMBRYONAL CARCINOMA

BHCG, AFP

Risk Factors BRCA

BRCA 1-chromosome region 17q21 BRCA 2-chromosome region 13 Both are associated with breast and ovarian cancers It appears to be a tumor suppressor gene that is highly expressed in ovarian borderline carcinoma

Condom Catheters Associated morbidities:

Bacteriuria Infection Penile cellulitis and necrosis Urinary retention and hydronephrosis with twisting or is too tight

Ovulation Tests

Basal body temperature: upon awakening the morning, the patient should take her temperature. Temperature rises 2 days after the peak of LH surge, coinciding with rise in peripheral levels of progesterone Urine LH kits: ovulation occurs approximately 24 hours after urinary evidence of the LH surge

Category I (normal) FHR tracings include all of the following

Baseline rate: 110-160 beats/min Baseline FHR variability: moderate Late or variable decelerations: absent Early decelerations: present or absent Accelerations: present or absent

Alloimunization

Because RhD immunization occurs in response to exposure of an RhD(-) mother to the RhD antigen, the mainstay for prevention is the avoidance of maternal exposure to the antigen. Rh immune globulin diminishes the availability of the RhD antigen to the maternal immune system. The routine prophylactic administration of Rh immune globulin at 28 weeks gestation is now the standard of care.

Menstrual Phase

Because it is the only portion of the cycle that is visible externally, the first day of menstruation is taken as day 1 of the menstrual cycle. The first 4 to 5 days of the cycle are defined as the menstrual phase. During this phase, there is disruption and disintegration of the endometrial glands and stroma, and red blood cell extravasation.

Early Pregnancy Loss

Because the incidence of conception is unknown, the incidence of spontaneous abortion (miscarriage) cannot be determined with certainty. Spontaneous abortion occurs in 10-15% of clinically recognizable pregnancies. When both clinical and biochemical pregnancies are considered, evidence would suggest that more than 50% of all conceptions are lost, the majority in the 14 days following conception. If a live, appropriately growing fetus is present at 8 weeks' gestation, the fetal loss rate over the next 20 weeks (up to 28 weeks) is in the order of 3%.

Development of the External Genitalia

Before the seventh week of development, the appearance of the external genital area is the same in males and females. The lateral genital folds develop into the labia majora Whereas the urogenital folds develop subsequently into the labia minora and prepuce of the clitoris. The external genitalia of the fetus are readily distinguishable as female at approximately 12 weeks

Patient Visits: Normal Pregnancy

Beginning at 28 weeks, systematic examination of the abdomen should be carried out at each prenatal visit to identify the lie (e.g., longitudinal, transverse, oblique), presentation (e.g., vertex, breech, shoulder), and position (e.g., flexion, extension, or rotation of the occiput) of the fetus.

Late FHR Deceleration

Believed to represent uteroplacental Insufficiency. This pattern has an onset, maximal decrease, and recovery that are shifted to the right in relation to the contraction. Fetal hypoxia and acidosis are usually more pronounced with severe decelerations. Severe, repetitive late decelerations usually indicate fetal metabolic acidosis, low arterial pH

Epithelial Related Calcifications in breast

Benign Calcifications Found in normal ducts, lobules, stroma, and blood vessel walls.

Biological effects of E and P in non-reproductive tissues: Bone Liver Integument Cardio CNS Kidney Adipose

Bone: epiphyseal plate closure of long bones in both sexes. Estradiol-17b (E2) has a bone anabolic effect and calciotropic effect. E2 stimulates intestinal Ca absorption and renal Ca re-absorption E2 promotes survival of osteoblasts and apoptosis of osteoclasts, therefore favoring bone formation Liver: E improves circulating lipoprotein profiles E increases expression of LDL receptor for enhanced clearance E increases circulating levels of HDL Integument: E and P maintain healthy skin. E and P increase collagen synthesis in the dermis and suppress matrix metalloproteases. E increases glycosaminoglycan production E promotes wound healing Cardiovascular: E promotes vasodilation via increased production of nitric oxide. Premenopausal women have significantly lower cardiovascular disease than men or postmenopausal women. CNS: in general E is neuroprotective (ie. inhibits neuronal cell death in response to hypoxia or other insults.) E has positive effect on angiogenesis P acts on hypothalamus to alter thermoregulatory set-point elevating body temp by ~0.5 -1.0 F. (during the cycle and also in pregnancy) Estrogens are known to block one of the enzymes (monoamine oxidase - MAO) that degrade serotonin, resulting in an elevation of mood. Progestogens, increase MAO concentration thus producing depression and irritability. Therefore the ratio of circulating sex-steroids can alter mood. Kidney: P is a competitive inhibitor of aldosterone, so P has a natriuretic action on the kidney. Adipose: Lipolytic effect Decreases lipoprotein lipase activity and increases hormone-sensitive liipase. Loss of E results in accumulation of adipose, esp. in abdominal area.

Pelvic Anatomy

Bony Pelvis The bony pelvis is made up of four bones: the sacrum, coccyx, and two innominates (composed of the ilium, ischium, and pubis). The sacrum consists of five fused vertebrae. The coccyx is composed of three to five rudimentary vertebrae. It articulates with the sacrum, forming a joint, and occasionally the bones are fused. The true pelvis is a bony canal and is formed by the sacrum and coccyx posteriorly and by the ischium and pubis laterally and anteriorly.

HIV ELISA and Western Blot

Both are extremely sensitive May be false negative in first 2 weeks infection Check HIV RNA and core P24 antigen Recent exposure: check ELISA at 6 weeks and repeat 3 months Kits available for saliva and urine with results in 30 minutes (confirm with Western Blot for all positives).

TUMOR MARKERS for Epithelial tumors

CA 125

2010 CDC Outpatient guidelines PID treatment

Ceftriaxone 250mg IM x 1 PLUS doxycycline 100mg po BID x 14d +/- metronidazole 500mg po BID x 14d Cefoxitin 2g IM x 1 and probenecid 1g po x 1 PLUS doxycycline 100mg po BID x 14d +/- metronidazole 500mg po BID x 14 d Cefoxitin-second gen cephalosporin/ probenecid- 1. Probenecid inhibits the tubular secretion of penicillin thus increasing the serum concentration of penicillin. 2. Lesser dose of Penicillin is needed3. Therefore, there will be less side effects of penicillin

Direct Coomb's test

Checks for Mothers ab on the baby's RBC by the binding of anti-Hu IgG (Coombs reagent) Example: the babys sample is positive for the presence of the mothers ab on the surface of the RBC's in erythroblastosis fetalis

Breast Pain-Other considerations

Costochondritis Rib somatic dysfunction Radicular pain Shingles

Infertility: Counseling

Counseling of patients who are treated with ART should include information regarding: Risk of multiple gestation Ethical issues surrounding multifetal pregnancy reduction Stress associated with undergoing ART Adoption

Müllerian Dysgenesis or Agenesis Treatments

Creation of a neovagina Vaginal dilation Vaginoplasty Congenital anatomic abnormalities of the uterus or vagina, or both, are often associated with renal abnormalities such as a unilateral solitary kidney or a double renal collecting system, among others. Therefore, for these patients, an intravenous pyelogram or other diagnostic radiographic study should be obtained to confirm a normal urinary system.

Treatment/follow up for pap smear results

Cytology and HPV Neg= Routine 3 yr screen Cytology Neg, HPV pos= Repeat both in 12 mo Cytology ASC-US, HPV neg= Repeat cytology in 12 mo Cytolgy ASC-US, HPV pos= Colposcopy Cytolgy>ASC-US, any HPV= Colposcopy

Age-related Changes of the Lower Urinary Tract

Decrease in bladder contractility Increase in uninhibited bladder contractions Diurnal urine output is shifted later in the day Sphincter striated muscle attenuation Decreased bladder capacity Increase (modest) in post-void residual (PVR) Decreased urethral closure pressure and vaginal mucosal atrophy (women)

Abruptio Placenta

Defined as: Premature separation of the normally implanted placenta Occurs in 1 in 200-300 deliveries 25% Perinatal mortality with placental abruption May be partial or complete, obvious or occult The placenta is attached to the uterine wall - May detach from the wall before or during labor -May cause vaginal bleeding. -Often causes pain, even if bleeding is light or not seen. When the placenta becomes detached, the fetus may get less oxygen. This can pose a danger. Only 1% of pregnant women have this problem. It usually occurs in the last 12 weeks before birth. Those at high risk include women who: - already had children - older than 35 years -previous abruption - sickle cell anemia

Preterm Labor

Definition and Incidence Preterm birth (PTB) is usually defined as one occurring after 20 weeks and before 37 completed weeks of gestation. Because prematurity is the leading cause of infant mortality, the prevention of prematurity has become a high priority.

Established UI: Stress Urinary Incontinence

Definition: leakage associated with sneezing, coughing, or physical activity Mechanism of leakage: Damage to pelvic floor supports (levator ani, connective tissues) Compress urethra when intra-abdominal pressure increases Sphincter failure Surgical damage or severe atrophy Sub-sacral spinal cord injury (rare) Second most common cause in women; seen in men after prostatectomy Stress incontinence occurs when the pelvic muscles aren't strong enough to withstand pressure pushing on the bladder.

Established UI: Urge Urinary Incontinence

Definition: leakage associated with urgency Most common cause in women and men Overlaps with detrusor overactivity (DO) or overactive bladder Causes of overactive detrusor: Idiopathic Age-related Lesions affecting cerebral and spinal cord inhibitory pathways Bladder outlet obstruction Bladder irritation (e.g. infection, stone, tumor) Mixed type: due to DO and impaired sphincter function/support Bladder is sensitive to signals that trigger contractions

Transient Incontinence:Potentially Reversible Causes "Diappers"

Delirium Infection Atrophic vaginitis/urethritis Pharmaceuticals Psychological Excess urine output Restricted mobility Stool impaction

Preeclampsia: Evaluation & Management

Delivery is the only definitive cure for preeclampsia A woman with mild preeclampsia whose disease presents at or beyond 37 weeks' gestation should usually be delivered A woman with severe preeclampsia or eclampsia whose disease presents at or beyond 34 weeks' gestation should usually be delivered after a brief period of stabilization. In some instances, stabilization of the patient with severe preeclampsia with magnesium sulfate for seizure prophylaxis medical control of severe hypertension: S > 160 mmHg or D > 110 mmHg should be treated promptly corticosteroids for fetal lung maturity these measures can moderate the disease process and delay delivery in a hope to advance gestational age.

Dysgerminoma

Derived from the germ cell of the ovary Occur in younger women under the age of 30 Are bilateral in 10% of cases the most common type of malignant cell germ tumor 15% secrete Hcg

Early Syphilis - Diagnosis and Treatment

Diagnosis: Clinical presentation Darkfield microscopy *Serology RPR- yes or no* VDRL- confirmatory* Treatment: PCN G 2.4 million units x 1 Doxycycline, Tetracycline, Ceftriaxone, Azithromycin

AUB-P (POLYPS) diagnosis When to do Polypectomy

Diagnosis: Visually or with PUS Polypectomy (When to do) : Symptomatic Greater than 1.5cm Multiple polyps Prolapsed Infertility Postmenopausal

Prostate Cancer Diagnosis

Digital rectal exam* prostate specific antigen* (PSA - age adjusted) -Start yearly PSA screening at age 50 (40 for African American and family history of prostate cancer)** -A gentle prostate exam will not elevate PSA.* -Prostatitis, BPH will raise the PSA.* Transrectal US* Prostatic acid phosphatase (PAP) * Biopsy* CT * Bone Scan

STIs Facilitate HIV Transmission

Disruption of epithelial/mucosal barriers Allow HIV cells to bind to CD4 receptors on "scout" cells Increase the number of HIV target cells in the genital tract Increase expression of HIV co-receptors Induce secretion of cytokines (increase HIV shedding) HIV alters natural history of some STIs STDs facilitate the transmission and acquisition of HIV through a variety of mechanisms. Disruption of epithelial and/or mucosal barriers will expose subepithelial lymphocytes and Langerhans cells to HIV. These breaches of a normal barrier results in a portal of entry and exit for HIV. The induction of cytokine secretion may result in increased HIV shedding. HIV shedding has been documented in the presence of genital ulcer disease as well as urethritis and cervicitis. Finally, HIV may alter the natural history of some STIs. For instance, it has been documented in the literature that HIV-infected individuals with genital herpes experience more frequent reactivation (clinically and asymptomatic) and often experience longer-lasting and more extensive ulceration than normal hosts. All of these changes may increase the duration of infectiousness both for the STI and HIV and contribute to continued transmission.

History: Incontinence Specific Questions

Do you leak urine most often: When you are performing some physical activity, such as coughing, sneezing, lifting, or exercising? (stress UI) When you have the urge or feeling that you need to empty your bladder but cannot get to the toilet fast enough? (urge UI) With both physical activity and a sense of urgency? (mixed UI) Without physical activity and without sense of urgency? (other)

Priapism Causes

Due to increased inflow or decreased outflow of blood in the penis* Most commonly seen with sickle cell disease or sickle cell trait Commonly caused by drugs Other causes include: blood clots, leukemia, a tumor in the pelvis, and an injury to the spinal cord

Normal Menstrual Bleeding

Duration less than seven days Flow less than 80 mL/cycle (Less than six full pads or tampons per day) Occurs approx every 21 -35 days No Intermenstrual Bleeding No Postcoital Spotting

Ovarian Cycle: Estrogens

During early follicular development, circulating estradiol levels are relatively low. About 1 week before ovulation, levels begin to increase, at first slowly, then rapidly. The levels generally reach a maximum 1 day before the midcycle LH peak. After this peak and before ovulation, there is a marked and precipitous fall. During the luteal phase, estradiol rises to a maximum 5 to 7 days after ovulation and returns to baseline shortly before menstruation.

Ovarian Cycle: Progestins

During follicular development, the ovary secretes only very small amounts of progesterone. Just before ovulation, the unruptured but luteinizing graafian follicle begins to produce increasing amounts of progesterone. The elevation of basal body temperature is temporally related to the central effect of progesterone. As with estradiol, secretion of progestins by the corpus luteum reaches a maximum 5 to 7 days after ovulation and returns to baseline shortly before menstruation. Should pregnancy occur, progesterone levels, and therefore basal body temperature, remain elevated.

Placental Metabolism

During pregnancy, the placenta accomplishes: Glycogen synthesis for energy reserver Cholesterol synthesis from fatty acids Protein metabolism Lactate removal Sources of nutrients and energy for the embryo and fetus

Epididymitis: Dx

Dx generally made based on physical examination findings and may be confirmed with urine studies (UA and culture) Ultrasound* Urine studies are often negative in patients without urinary complaints A urethral swab should be obtained in patients with urethral discharge and sent for culture and nucleic acid amplification testing for chlamydia and gonorrhea Ultrasound should be performed in patients with acute onset of testicular pain to assess for testicular torsion

AUB-C (COAGULOPATHY)

Etiologies Von Willebrand's Thrombocytopenia 1 Factor XI 2 CBC 3 Liver Panel 4 PT/PTT 5 Serum HCG

Nongonococcal Urethritis

Etiology: 20-40% C. trachomatis 20-30% genital mycoplasmas Mycoplasma genitalium, Ureaplasma urealyticum) Occasional Trichomonas vaginalis, HSV Unknown in ~50% cases Sx: Mild dysuria, mucoid discharge Dx: Urethral smear > 5 PMNs/OI field  Urine microscopic > 10 PMNs/HPF Leukocyte esterase (+)

Diagnosis Endometrial CaAbdominal/Transvaginal Ultrasound

Evaluate endometrial stripe Stripe < 4mm Unlikely risk of endometrial hyperplasia or cancer Stripe from 5-12 mm May be normal Stripe > 5mm Biopsy Postmenopausal women Stripe > 11mm Bx (6.7% Risk of Malignancy)

Polycystic Ovarian Syndrome Testing after diagnosis

Evaluation due to increased risks Lipid panel Endometrial sampling HgbA1c

Intrauterine Growth Restriction: Fetal

Examples of fetal causes include intrauterine infection (listeriosis and TORCH [toxoplasmosis, other infections, rubella, cytomegalovirus infection, and herpes simplex] agents) and congenital anomalies Clinical Manifestations Two types of fetal growth restriction have been described: symmetric and asymmetric. When asymmetric growth restriction occurs, usually late in pregnancy, the brain is preferentially spared at the expense of abdominal viscera.

Controlled Ovarian Hyperstimulation

Exogenous gonadotropins can be given to stimulate follicular development Aims to achieve monofollicular ovulation in anovulatory women

Radiation Therapy for adenexal masses

External beam radiation therapy is as effective as chemotherapy for patients with early stages of ovarian carcinoma who have no visible cancer remaining after their operation Sometimes radiation therapy is used for microscopic persistent ovarian cancer or cancer that has not responded well to chemotherapy may be given only to the pelvis or more typically, to the entire abdomen (usually five days each week for four to five weeks Radioactive phosphate inserted directly into the abdominal cavity is sometimes given to women who have no visible cancer or less than 1 mm of residual disease after surgery

Menstruation and Menopause

Female gametes are of a fixed number that progressively diminish throughout a woman's reproductive life. At the time of birth, the female infant has approximately 1-2 million oocytes. By puberty, she has about 400,000 oocytes remaining. By 30 to 35 the number of oocytes has decreased to ~100,000. During the reproductive cycle, a cohort of oocytes is stimulated to begin maturation, but only 1 or 2 dominant follicles complete the process and are ovulated. Follicular maturation is induced and stimulated by FSH and LH (released by the pituitary). With advancing age, the remaining oocytes become increasingly resistant to FSH and FSH levels begin to increase several years in advance of menopause. FSH levels (mIU/mL) Reproductive years: 6 - 10 Perimenopause: 14 - 24 Menopause: > 30

AUB-M (MALIGNANCY)

Fibroids Endometrial CA Cervical CA Endometrial polyps Endometrial hyperplasia

hCG (human chorionic gonadotropin)

First key hormone of pregnancy produced by placental cells and appears in serum within 9 days hCG has 2 subunits a and b. a identical for FSH, LH and TSH. The b subunit has 80% homology to b subunit of LH hCG secreted by SCT layer which is stimulated by LHRH from CT layer. (paracrine action) hCG peaks at 9-12 weeks and then plateaus Supports the corpus luteum until the placenta can produce its own estrogen and progesterone Rapid rise in hCG is responsible for the feeling of "moring sickness" in some women A small amout of hCG enters fetal circulation (1% - 10%) In male fetuses, hCG stimulates Leydig cells to produce the testosterone critical for sexual differentiation

Vulvar Fistulas

Fistulas from the bladder into the vagina can form as a result of surgical complications, prolonged pressure applied during labor, or malignancies. Fistulas from the bowel into the vagina can result from incomplete healing of fourth degree lacerations Surgical complications Malignancies Granulomatous processes, such as tuberculosis or Crohn disease.

Simple Breast Cysts

Fluid filled round or ovid masses Derived from the terminal duct lobule Common in women 35-50yrs Influenced by hormonal flucuation Present with painful/painless often solitary mass Can not distinguish from a benign cyst or malignancy with SBE or CBE Dx: Breast Ultrasound (Fluid or Solid) - FNA (Benign if non-bloody and completely collapses) No treatment required (Usually resolves in a few days)

Benign adnexal Cysts can form from

Follicular Corpus Luteum Theca Lutein Dermoid

Secretory Phase

Following ovulation, progesterone secretion by the corpus luteum stimulates the glandular cells to secrete glycogen, mucus, and other substances. The stroma becomes edematous. The marked changes that occur in endometrial histology during the secretory phase permit relatively precise timing (dating) of secretory endometrium. If pregnancy does not occur by day 23, the corpus luteum begins to regress, secretion of progesterone and estradiol declines, and the endometrium undergoes involution. About 1 day before the onset of menstruation, marked constriction of the spiral arterioles takes place, causing ischemia of the endometrium followed by leukocyte infiltration and red blood cell extravasation. The resulting necrosis causes menstruation or sloughing of the endometrium. Ironically, menstruation, which clinically marks the beginning of the menstrual cycle, is actually the terminal event of a physiologic process that enables the uterus to be prepared to receive another conceptus.

Indirect Hernias

Follows the tract through the inguinal canal. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.

Obstetric Forceps

Forceps are instruments designed to provide traction and/or rotation of the fetal head when the expulsive efforts of the mother are insufficient to accomplish safe delivery of the fetus. Classic or standard forceps are used to facilitate delivery by applying traction to the fetal skull.

Breast Pain - Cyclic

Generally in late luteal phase and resolves with menses Stimulation of the ducts with Estrogen Stimulation of the stroma with Progesterone Associated with premenstrual syndrome Seen more often in younger women Bilateral and poorly localized Heaviness or soreness

Treatment for PID When to admit

Generally outpatient management *Admit to hospital if: Surgical emergencies, such as appendicitis, can't be excluded. Pregnancy severe illness, nausea, vomiting, or high fever. tuboovarian abscess. immunodeficient --HIV infection with low CD4 counts --immunosuppressive therapy --Other disease that compromise immune system does not respond clinically to oral antimicrobial therapy. unable to follow or tolerate an outpatient oral regimen.

Estimating Gestational Age and Date of Confinement

Gestational age should be determined during the first prenatal visit. Ultrasonography may also be used to estimate gestational age.Measurement of fetal crown-rump length between 6 and 11 weeks' gestation can define gestational age to within 7 days. Modification of Nägele rule for establishing the EDC is to add 9 months and 7 days to the first day of the last normal menstrual period (LMP). For example: LMP: July 20, 2015 EDC: April 27, 2016 Between 16-36 weeks the fundal height can be used to estimate gestation 12 weeks: the fundus of the uterus is at the pubic symphysis 16 weeks: the fundus of the uterus half way between pubic symphysis and umbilicus 20 weeks: the fundus of the uterus is at umbilicus 34 week: the fundus of the uterus measures approximately 34 cm from the SP

Dilation and Curettage

Gold standard for Dx of Endometrial Ca Therapeutic Endometrial hyperplasia, endometrial polyps Do D&C if EMB is Negative/Inconclusive Endometrial hyperplasia Continued AUB General Anesthesia (sometimes paracervical block) Complications Perforation of uterus Bleeding Infection Laceration of the cervix

Placental abruption can be broadly classified into three grades that correlate with the following clinical and laboratory findings:

Grade 1: *A mild abruption* characterized by slight vaginal bleeding and minimal uterine irritability. Maternal blood pressure and fibrinogen levels are unaffected, and the fetal heart rate pattern is normal. Approximately 40 percent of placental abruptions are grade 1.  Grade 2: *A partial abruption* with mild to moderate vaginal bleeding and significant uterine irritability or contractions. Maternal blood pressure is maintained, but the pulse is often elevated and postural blood volume deficits may be present. The fibrinogen level may be decreased, and the fetal heart rate often shows signs of fetal compromise. Grade 2 abruptions account for 45 percent of all placental abruptions.  Grade 3: *A large or complete abruption* characterized by moderate to severe vaginal bleeding or occult uterine bleeding with painful, tetanic uterine contractions. Maternal hypotension and coagulopathy are frequently present along with fetal death. Approximately 15 percent of placental abruptions are recognized as grade 3. Fetal tracing with placental abruption. A Decreased short-term variability B increased baseline uterine tone C Uterine hyperstimulation D Worsening variable decelerations

Ovarian Neoplasm Classifications: Sex Cord Stromal

Granulosa Thecal Sertoli Leydig Gonadoblastomas

Alternatives to HRT

Healthy lifestyle changes Healthy eating and diet Regular exercise Avoid smoking Limiting alcohol intake St. John's wort: hot flashes and mood disturbances Black cohosh: vasomotor symptoms

Breast Ultrasound

Helpful when the lesion of interest is not palpable or poorly characterized by mammography Assists in directing biopsy Ideal for evaluation of axilla

When Should I Refer the Patient? Refer to urology/urogynecology/gynecology for:

Hematuria Recurrent symptomatic urinary infections Pelvic mass Hx of pelvic irradiation, pelvic surgery Urge incontinence with pain Significant pelvic organ prolapse Suspected fistula

Hydrops Fetalis

Hemolytic Anemia in the fetus Causes swollen liver and severe abd swelling Caused by Rh+ in Mother that is Rh-

Cystine Stones

Hexagonal shaped crystals indicating hypercystinuria (480-3600mg/24hrs) Tx with increased volume intake and alkalinization of the urine (pH>7) Penicillamine or tiopronine can be used ECSWL is ineffective Ultrasonic lithotripsy is used

Breast Pain - Diagnostics

History and Clinical Breast Exam Treat findings as appropriate Over 35 and normal exam --Mammogram to r/o other pathology Under 35 and normal exam --Reassurance Consider pain diary

When do we begin screening for osteoporosis? Who are the exceptions?

History of a fragility fracture Weight < 127 lbs Medical causes of bone loss Parental history of hip fracture Smoker Alcoholism Rheumatoid arthritis

Ultrasound of Endometrioma/Hemorrhagic Cyst

Homogeneous appearance may suggest endometrioma Reticular pattern may suggest hemorrhagic cyst

Unopposed Estrogen Exposure and endometrial ca

Hormone Replacement Therapy (HRT) Estrogen replacement for menopausal symptoms 4-8 x risk than patient on combo HRT Polycystic Ovarian Syndrome (PCOS) Anovulatory cycle

Management of Menopause

Hormone replacement therapy (HRT): the objective of its use is to minimize the symptoms of menopause. Estrogen Therapy Oral Transdermal Topical Combined Estrogen and Progestin Therapy The administration of continuous unopposed estrogen can result in endometrial hyperplasia and an increased risk of endometrial cancer. A progestin must be administered in conjunction with an estrogen if the woman has not undergone hysterectomy. A progestin would be provided in sequential dosing for ~14 days of each month.

Placental Endocrine Secretion

Human chorionic gonadotropin (HCG) Human Placental Lactogen (hPL), now goes by "chorionic somatomammotropin (hCS) Gonadotropin-releasing hormone (GnRH) Somatostatin, inhibits production of human chorionic somatomammotropin (hCS) Estrogen Progesterone Glucocorticoids

Amenorrhea or Oligomenorrhea with Hyperandrogenism

Hyperandrogenism is the clinical manifestation of elevated circulating levels of male hormones in women. Features may range from mild, unwanted excessive hair growth and acne to alopecia (hair loss), hirsutism, and virilization. *Hirsutism*: excessive terminal hair appearing in a male-type pattern. *Virilization (masculinization)*: refers to the acquisition of male characteristics (i.e., temporal balding, deepening of the voice, and enlargement of the clitoris).

Hypogonadotropic hypogonadism

Hypogonadotropic hypogonadism may be caused by lesions of the hypothalamus or pituitary gland or by functional disorders that suppress gonadotropin-releasing hormone (GnRH) synthesis and release. Pituitary tumor Kallmann syndrome CNS tumor Constitutionally delayed puberty Because patients with sexual infantilism caused by hypogonadotropic hypogonadism may have a craniopharyngioma or other central nervous system (CNS) tumor, magnetic resonance imaging (MRI) or computed tomography (CT) of the hypothalamic-pituitary area is recommended.

Each female reproductive cycle (menstrual cycle) represents a complex interaction between the

Hypothalamus Pituitary gland Ovaries Endometrium Cyclic changes in the gonadotropins Luteinizing hormone (LH), and Follicle-stimulating hormone (FSH) and Sex steroid hormones, mainly estradiol (E2) and progesterone (P4) These hormones induce functional as well as morphologic changes in the ovary, resulting in Follicular maturation Ovulation Corpus luteum formation Similar changes at the level of the endometrium allow for successful implantation of the fertilized ovum or a physiologic shedding of the menstrual endometrium when an early pregnancy does not occur. By convention, the normal cycle begins on the first day of menstrual bleeding and ends just before the first day of the next menses. The average length of each cycle is 28 (±7) days.

Depot Medroxyprogesterone

IM or SQ injection of progestin every 3 months Keep progestin high to block LH surge and ovulation Thickens cervical mucus Side effects Adverse effects on bone mineral density? Menstrual irregularities Weight gain Breast tenderness Fatigue

TUMOR MARKERS for GRANULOSA CELL TUMOR

INHIBIN

Preconception Care

Ideally, "prenatal care" should begin before pregnancy. Organogenesis begins early in pregnancy and placental development starts with implantation, about 7 days after conception. For some, preconception care means a single prepregnancy check-up a few months before couples attempt to conceive. A single visit, however, may be inadequate to address some problems such as smoking cessation or attaining and maintaining a healthy weight. For others, preconception care should become an important part of comprehensive well-woman care, universally implemented from prepubescence to menopause.

Erythrocytosis fetalis

Immature reticulocytes the response to hemoloysis trying to make up for the RBCs attacked by maternal antibodies to the RhD+ fetus/baby

Postpartum Mastitis -Treatment

Improve breast feeding technique Antibiotics Dicloxacillin Amoxicillin-clavulanate Cephalexin (Keflex) 10-14 day course MRSA Consider if not improving after 2 days Trimethoprim/sulfamethoxazole (Bactrim) Abscess Confirm w/ultrasound Surgical drainage or needle aspiration

Epididymitis: PE Findings for acute and chronic cases

In *Acute* infectious epididymitis, palpation reveals induration and swelling of the involved epididymis with exquisite tenderness. More advanced cases often present with testicular swelling and pain with scrotal wall erythema and a reactive hydrocele In *Chronic* cases, shows more subtle epididymal induration and tenderness, with or without swelling. In cases where severe testicular pain is present, testicular torsion and Fournier's gangrene must be considered in the differential diagnosis Sometimes an inflammatory nodule is felt with an otherwise soft, nontender epididymis

Uterine cycle:Menstruation

In a non-fertile cycle the corpus luteum dies and there is a sudden withdrawal of P. This leads to a loss of the lamina functionalis and sloughing of the uterine lining. Lasts 4-5 days. ~25-35ml of blood lost during this time.

All contraceptives work by either 2 general mechanisms of action:

Inhibit the development or release of the ovum Blocking the meeting of ova and sperm

Nephrolithiasis: Presenting signs, symptoms and physical findings

Intense, sharp flank pain. Can radiate (or migrate) to low abdomen or into groin or testicles in men Positive kidney punch test Generally benign abdominal exam although may have decreased bowel sounds, and no dysuria Tachycardia and increased blood pressure. May be febrile. Emesis and ileus common Pain can come and go if stone stops

Intrauterine Fetal Demise

Intrauterine fetal demise (IUFD) is fetal death after 20 weeks' gestation but before the onset of labor. It complicates about 1% of pregnancies. *Etiology* In more than 50% of cases, the etiology of antepartum fetal death is not known or cannot be determined. *Management* Fetal demise between 14 and 28 weeks allows for two different approaches: watchful expectancy and induction of labor. *Watchful Expectancy* About 80% of patients experience the spontaneous onset of labor within 2 to 3 weeks of fetal demise. After 28 weeks' gestation, if the condition of the cervix is favorable for induction and there are no contraindications, Cytotec followed by oxytocin are the drugs of choice.

Intrauterine Growth Restriction

Intrauterine growth restriction (IUGR) by definition occurs when the birth weight of a newborn infant is below the 10th percentile for a given gestational age. Growth-restricted fetuses are particularly prone to problems such as meconium aspiration, asphyxia, polycythemia, hypoglycemia, and mental retardation. They are at greater risk for developing adult onset conditions such as hypertension, diabetes, and atherosclerosis *Etiology* The causes of IUGR can be grouped into three main categories: maternal, placental, and fetal.

Radical Hysterectomy

Involves the wide excision of the parametrial tissue laterally along with the uterosacral ligaments posteriorly, after the rectum is dissected free and after each ureter is dissected out of its tunnel beneath the uterine artery.

A total abdominal hysterectomy (TAH)

Is the most commonly performed procedure for benign uterine disease and involves the simple excision of the uterine corpus and cervix If the adnexa are to be removed, the ureters are identified and the infundibulopelvic ligaments with the ovarian vessels are clamped, cut, and tied.

Speculum Examination

It is important to use an appropriately sized speculum The speculum should be lubricated After gently spreading the labia to expose the introitus, the speculum should be inserted with the blades entering the introitus transversely, then directed posteriorly in the axis of the vagina with pressure exerted against the relatively insensitive perineum to avoid contacting the sensitive urethra. As the anterior blade reaches the cervix, the speculum is opened to bring the cervix into view Vaginal wall relaxation should be evaluated using either a Sims speculum or the posterior blade of a bivalve speculum.

PALM-COEIN

June 7, 2011 — The International Federation of Gynecology and Obstetrics (FIGO) has approved a new classification system (PALM-COEIN) for causes of abnormal uterine bleeding (AUB) in non-gravid women of reproductive age. The new system, which is published in the June issue of the International Journal of Gynecology & Obstetrics, should facilitate basic science and clinical research, as well as the practical, rational, and consistent application of medical and surgical treatments.

Complete Mole

Karyotype most commonly 46,xx, or 46xy Fetus absent Amnion fetal blood cells absent Diffuse villous edema Trophoblastic proliferation slight to severe 15%-25% theca lutein cysts Malignant sequela 6%-32% Snowstorm appearance on US Uterus large for dates Theca lutein cysts Characteristic hydropic villi on ultrasound Hyperemesis Often develop serious medical complications Embolization of trophoblastic tissue Thyrotoxicosis PIH Can progress to Gestational Trophoblastic Disease

Breast Cancer

Life Time Risk for Women is 12% (1 in 8) Risk Factors for Breast Cancer Age - older Race - white Family Hx - 1st degree relative (mother, sister, or daughter) Genetics - BRCA1 and BRCA2 mutation PMHX - Endometrial Ca, Proliferative fibrocystic disease, Ca in other breast Menstrual Hx - Early menarche(<12), Late menopause (> 50) ObHx - Nulliparous or late first pregnancy *Suspicious Mass* Solitary Discrete Hard Painless Adherent to surrounding tissue

Sclerosing Adenosis of the breast

Lobular lesion with increased fibrous tissue and interspersed glandular cells No treatment required

Progesterone during pregnancy

Maintains endometrium during pregnancy -helps prepare mammary glands -prepares mother for birth of baby Essential for implantation and maintenance of decidual lining May modulate secretion of hCG and hCS Placental P converted to cortisol and aldosterone for fetal use Stimulates decidual lining to secrete PRL Quiets uterine contraction (inhibits PG's) In mother P increases capacity of alveolar pouches to hold milk Stimulates respiratory center to get rid of excess CO2 produced by fetus About 90% of P used by mother only 10% by fetus

Malignant Tumors Ultrasound Features

Malignant tumors characteristically contain dilated, saccular, and randomly dispersed vessels Centrally located flow along septations flow within papillary excrescences

Priapism Treatment

Many cases resolve spontaneously after repeated ejaculation, physical activity or a brisk walk.* Oral terbutaline or salbutamol may help if given early.* Blood (50ml) can be removed by inserting a needle into the penis (often in conjunction with heparin and saline to reduce clotting).* In resistant cases, a reversing agent, metaraminol, may be injected into the penis.  In very rare cases, surgery is required to avoid permanent damage to the muscle of the penis Unresolved priapism can lead to severe damage to the tissues of the penis which can affect erections. In this case, an implant or prosthesis can be surgically placed within the penis.

Contraindications for Breast Feeding Maternal and fetal

Maternal HIV Abuse of Street Drugs (Methadone ok) Tcell Lymphoctic Infection Untreated TB (Ok two weeks after starting treatment) (Pumped milk ok) Chemo and Radiation Active Herpetic Breast Lesions ETOH Tobacco Fetal Galactosemia (Absolute Contraindication)

Intrauterine Growth Restriction: Maternal

Maternal causes include poor nutritional intake, cigarette smoking, drug abuse, early cardiovascular disease, hypertension, diabetes, obesity (associated with leptin resistance), alcoholism, cyanotic heart disease, and pulmonary insufficiency.

Intraductal Papilloma of the breast

May show up on mammogram, breast ultrasound, or MRI May have nipple discharge as presenting symptom Monotonous array of papillary cells that grow from the wall into the lumen Dx: Ductogram Tx: Excision (No additional treatment if excision shows no atypia)

Combination Oral Contraceptives MOA Other uses

Mechanism of Action: Estrogen + Progesterone Estrogen: stabilizes endometrium for regular cycles and less breakthrough bleeding Progesterone: suppresses secretion of LH => suppresses ovulation (main contraceptive effect) Other Uses Primary dysmenorrhea PCOS Endometriosis Premenstrual dysphoric disorder Acne

Signs & Symptoms of Menopause

Menopause is a physiologic process that can be associated with symptoms that can affect a woman's quality of life. Hormone therapy can help with most of these symptoms. Menstrual Cycle Alterations After the age of 40 a woman may note subtle changes in her cycle. The luteal phase stays consistent, 13 to 14 days. The variation in cycle is related to the follicular phase. With increase in age ovulation frequency may decrease to 3-4 times a year.

changes during the menstrual cycle Metabolic Cervix: Breasts

Metabolic P is responsible for an increase in basal body temp 0.4 to 1° C Cervix: E stimulates production of thin, slightly alkaline mucus that creates and ideal environment for sperm. P stimulates production of scant, viscous, acidic mucus that does not promote sperm. Breasts E enhances duct growth P responsible for alveolar development

Recommendations for Breast Feeding benefits for mom and infant

Mom Reduced length of lochia (Bleeding postpartum) Reduced stress (2nd to hormonal release) Increased weight loss (If greater than 6months) Decreased risk of breast cancer Decreased cost (formula/supplies approx $1000/yr) Infant Better digestive tract formation Decreased infections/ear infections Possible decreased CVD, autoimmune disease, obesity, and Type I DM

What Are the Other Consequences of UI?

Morbidities Dermatitis and cellulitis Pressure ulcers Urinary tract infections Sexual dysfunction Falls and fracture risk Sleep deprivation Depression

HIV Epidemiology

More than 60 million infected with HIV-1 ~90% from developing nations ~40% through heterosexual intercourse HIV -1 closely related to chimpanzee SIV HIV-2 more closely related to SIV in sooty mangabey. Slightly longer latency period Remember vertical transmission 25-30% of infants born to non-treated mothers will be infected! SIV = simian immunodeficiency virus

Focal Lesions in CNS associated with HIV

New onset seizures, headaches, fevers, rapid progressive cognitive impairment. Need MRI, CT with Contrast (especially if MRI not available), CSF evaluation, toxoplasmosis titers.

What About Nocturia?

Nocturia is a nonspecific symptom Look for other causes other than urge urinary incontinence or prostate disease Causes: 1. Nocturnal polyuria Late day/evening fluids, specially with caffeine or alcohol Pedal edema Heart failure Obstructive sleep apnea (OSA) 2. Sleep disturbance Medications Cardiac or pulmonary disease Pain Restless leg syndrome Depression Obstructive sleep apnea Sleep partner 3. Lower urinary tract Detrusor overactivity Benign prostatic hypertrophy Impaired bladder emptying OSA and nocturia: Thought to secondary to increase in ANP (atrial natriuretic peptide) due to perceived volume overload due to sympathetic stimulation

HPV: *Prevention

Non-vaccine modalities: Decrease number of partners Condoms 70% reduction in newly sexually active college women when partners consistently used condoms Shown to reduce incident infection, associated with lower rate of cervical cancer and associated with regression of HPV-related cervical and penile lesions Treatment of warts Smoking cessation

Hypothalamic-pituitaryovarian-axis

Note that estrogen and progesterone can exert both positive and negative feedback control of the hypothalamus and pituitary depending on the phase of the menstrual cycle.

Treating PCOS

OCP Cyclic medroxyprogesterone 10mg for 10-12 days a month Metformin (insulin resistance) Spironolactone (hirsutism) Clomid (Pregnancy)

AUB-I (IATROGENIC)

OCP Misuse ASA Anticoagulation Use Tamoxifen IUD Trauma Laceration Abrasion Foreign Body Other Pregnancy Abortion Liver Disease Thyroid Disease

Risk Factors for Endometrial Ca

Obesity Nulliparity Late Menopause Diabetes Mellitus Hypertension Breast, Colon, or Ovarian CA Chronic Unopposed Estrogen Stimulation Chronic Tamoxifen Use

Breastfeeding / Mastitis

On approximately the second day after delivery, colostrum is secreted. Its content is composed mostly of protein, fat, and minerals. It is the colostrum that contains secretory IgA. After about 3 to 6 days, the colostrum is replaced by mature milk. *Mastitis* The etiologic agent is usually Staphylococcus aureus, which originates from the infant's oral pharynx. Because the majority of staphylococcal organisms are penicillinase-producing, a penicillinase-resistant antibiotic, such as dicloxacillin, should be used.

AUB-P (POLYPS)

One of the most common etiologies for abnormal genital tract bleeding in both pre- and post- menopausal women Hyperplastic overgrowth of endometrial glands and stroma leading to projection from the surface of the endometrium Possibly asymptomatic 95% Benign Increased prevalence with age Risk Factors: Increased Endogenous and Exogenous Estrogen Increased with Tamoxifen Increased with Obesity Decreased with Mirena Presenting Symptoms: Metrorrhagia PMVB

Succenturiate Placenta

One or more accessory lobes 3% incidence Often causing severe hemorrhage An extra placenta separate from the main placenta In anatomy succenturiate" means accessory to an organ an accessory placenta

Words for Rh sensitivity

Osponize red blood cells Epitope Exon Apoptosis SNPs Orthotopic Alloimmunity

Treatment of Infertility: Ovarian Stimulation Drug?

Ovulation induction is indicated in women with anovulation or oligo-ovulation *Clomiphene (clomid)* Clomiphene is a selective estrogen receptor modulator (SERM). The anti-estrogen effects induce gonadotropin release from the pituitary which stimulates follicle development. Clomiphene is administered daily x 5 days in the follicular phase Ovulation occurs from 5 to 12 days after the last pill Ovulation is monitored in several ways TVUS is performed on cycle day 11 or 12 to identify a developing follicle. A mature follicle (>18 mm)

DIFFERENTIAL FOR AUB PALM-COEIN

P: Polyps A: Adenomyosis L: Leiomyoma M: Malignancy (PALM = Structural Causes of AUB) C: Coagulopathy O: Ovulatory Disorder E: Endometrial I: Iatrogenic N: Not Classified (COEIN = Non-Structural Causes)

Common causes of ovulatory dysfunction and amenorrhea in reproductive women:

PCOS Thyroid disorders Hyperprolactinemia Pregnancy Ovarian failure Obstruction of the reproductive tract

PCOS Treatment

PCOS is associated with a fourfold increased prevalence of type 2 diabetes mellitus. Some patients with PCOS also may have several risk factors for cardiovascular disease, including increased abdominal adiposity, hypertension, hypertriglyceridemia, and low-density lipoprotein cholesterol levels and decreased high-density lipoprotein cholesterol levels. Controlling for body mass index, women with PCOS are more likely to have sleep-disordered breathing and daytime sleepiness than healthy women

Magnesium Ammonium Phosphate (Struvite or triple phosphate stones)

PMH includes multiple UTI's with urease producing organisms (Proteus and Providencia species) and antibiotic tx. Results in formation of ammonium, urine alkalinization ppt struvite and apatite. Ammonium phosphate traps Ca+ and Mg+ results in magnesium ammonium phosphate stones which are radiopaque & staghorn 40% have hypercalciuria, 15% have hyperuricosuria as nidus of stone formation Tx aimed at infectious risk factors

Chancroid

Painful necrotizing genital ulcers may be accompanied by inguinal lymphadenopathy. underdeveloped regions Asia, Africa, and the Caribbean outbreaks occur in cities among workers in the sex trade.

Primary Amenorrhea w/ Breast Development & Müllerian Anomalies

Patients fall into two categories: those with complete androgen insensitivity syndrome (AIS), formerly called testicular feminization those with müllerian dysgenesis or agenesis.

Androgen Insensitivity Syndrome

Patients with complete AIS have a defect in the androgen receptor. Their karyotype is 46,XY, and they demonstrate male levels of testosterone Breast development (with nipples and areolae smaller than a normal genotypical female's) is caused by the testicular secretion of estrogens and by the conversion of circulating androgen to estrogens in the liver and elsewhere. The testes of individuals with AIS secrete normal male amounts of anti-müllerian hormone (AMH); therefore, patients have only a vaginal dimple and no uterus

Pelvic Organ Prolapse

Pelvic organ prolapse (POP) refers to the protrusion of the pelvic organs into the vaginal canal or beyond the vaginal opening. It occurs because of a weakness in the endopelvic fascia Defects in vaginal support may occur in isolation (e.g., anterior vaginal wall only), but they are more commonly combined. The nomenclature of POP has evolved such that older terms such as cystocele, rectocele, and enterocele have been replaced by more anatomically precise terms Types: Bladder Uterine Rectocele/ back passage (rectum)

Placenta Accreta

Placenta accreta implies an abnormal attachment of the placenta through the uterine myometrium as a result of defective decidual formation (absent Nitabuch layer). Two-thirds of patients with this complication require hysterectomy when an attempt to remove the placenta leads to severe hemorrhage intrapartum. Presence of placenta previa: risk of accreta 1 CS: 3% 2 CS: 11% 3 CS: 40% 4 CS: 61% 5 CS: 67%

Placenta Accreta

Placental villi are attached to the myometrium

Morbidity associated with indwelling Foley catheters

Polymicrobial bacteriuria Febrile episodes Pyelonephritis and chronic renal inflammation Nephrolithiasis and bladder stones Epididymitis Meatal damage

Causes of Elevated Prolactin

Pregnancy Excessive exercise Stimulation of the chest wall or nipple Medications Craniophyryngiomas Severe head trauma Prolactinomas Chronic renal failure Marijuana or narcotic use

Prenatal Care: Follow-up Visits

Prenatal visits should be scheduled every 4 weeks until 28 weeks' gestation, every 2 to 3 weeks until 36 weeks, and then weekly until delivery. Women should be screened for depression early in pregnancy, during the third trimester and again postpartum. Screening for gestational diabetes should be performed between 24 and 28 weeks' gestation. Universal screening for maternal colonization of group B streptococcus at 35 to 37 weeks' gestation. Controlled trials have failed to demonstrate that routine ultrasonic examinations for dating in early pregnancy, anatomic survey in mid-pregnancy, or assessment of fetal growth in late pregnancy improve perinatal outcome.

Regulation of male reproduction:Hypothalamic-PituitaryTesticular axis

Production of male gametes in seminiferous tubules (under influence of FSH and testosterone) Androgen biosynthesis in Leydig cells (under influence of LH) Testosterone, DHT, and Estradiol 17b: (-) feedback on GnRH release and LH release Inhibin (-) feedback on FSH release Note: Testosterone, DHT and estrogen selectively inhibit LH more than FSH Inhibin directly inhibits FSH

Papillary Apocrine Change in breast

Proliferation of ductal epithelial cells (apocrine features)

Prostate Cancer

Prostate cancer is the most common malignancy in U.S. males and is the second leading cause of cancer death in men* Prostate cancer occurs in 1 out of 6 men.* Many are asymptomatic Risk Factors More common in African Americans* Family history* Increasing age*. Common after age 70.

Choriocarcinoma Diagnosis Prognosis Risk factors

Pure epithelial tumor composed of syncytiotrophoblastic and cytotrophoblastic cells May accompany or follow any type of pregnancy Presents as late vagina bleeding in the postpartum period ½ patients have preceeding molar pregnancy Initiator of other diseases-check for elevated B-hCG *Diagnosis*: Measure HCG levels CT scan brain, lungs, liver, and pelvis *Prognosis*: 1. Extensive choriocarcinoma at diagnosis 2. Lack of appropriate aggressive initial treatment 3. Failure of currently used chemotherapy *Risk factors*: Chorionic gonadotropin 40,000 mIU/ml Duration greater than 4 months Brain or liver metastases Prior chemotherapy failure Antecedent term pregnancy

Indirect Coomb's test

Put an RBC that is Rh+ in patients serum to see if there are antibodies.

Gardasil Vaccine

Quadrivalent vaccine HPV 6, 11,16,18 Females age 9-26 Males age 9-26 IM injection 0, 2, 6 months Most effective if given before onset of sexual activity

RPR (Rapid Plasma Reagin)

RPR was developed as a more advanced VDRL. RPR is just the VDRL antigen, but it contains carbon or delicately divided charcoal particles. With these charcoal particles, it allows the visualization of the reaction or flocculation between the specimen and the antigen without the use of a microscope. RPR tests can be done without the use of a microscope; the result can be seen by our naked eye. In contrast, a VDLR test requires a microscope to know the results of the test. Rapid Plasma Reagin, or RPR, is the most preferred syphilis test by many for it is easy to use and can be readily purchased in a kit form in contrast to the VDLR.

RH factor

Rh factor , Rhesus factor genetically determined antigens present on the surface of erythrocytes; incompatibility for these antigens between mother and offspring is responsible for erythroblastosis fetalis.

BREAST EXAM Types

SBE: Self Breast Exam CBE: Clinical Breast Exam Breast Self Awareness (which can include a SBE)

Peyronie's disease

Scarring or fibrosis in the tunic of the corpora - presents with mass in penis (may or not be painful) and abnormal curvature during erection* Very common Tx - Surgery* - surgical excision and replacement with graft (may result in erectile dysfunction or shortening) **Associated with Dupuytren's Contracture of the hand

Bishop score

Score of 0-3 Measures the position, consistency, Effacement (%), and Dilation (cm) of the cervix, and the distance of the fetal head (station) Higher ratings are achieved as the position of the cervix moves from posterior to anterior, becomes softer, achieves a higher effacemet, and dilation. Higher ratings are also achieved as the fetal head moves closer and past the ischial spines (Station). *0* Cervix: Posterior, Firm, 0-30%, 0 cm. Station -3 *1* Cervix: Mid, medium, 40-50%, 1-2 cm. Station -2 *2* Cervix: anterior, soft, 60-70%, 3-4 cm. Station -1 *3* Cervix: ant, soft, >80%, >5 cm. Station +1

Testicular Cancer Treatment

See surgeon within a week of diagnosis.* Good survival if diagnosed early* Inguinal incision - Remove testicle*(orchiectomy) Don't biopsy because you can seed into the scrotal skin and change the lymphatic drainage If it is a seminoma - Radiation therapy to the lymph nodes of the primary drainage (iliac areas) If it is not a seminoma - must dissect the draining lymph nodes

Male Infertility

Semen analysis is obtained after 2-3 days of abstinence Analysis is performed within 1 hours of ejaculation Standard semen analysis evaluates: Quantity Quality Sperm concentration Sperm motility Sperm morphology If results of semen analysis are abnormal, testing should be repeated in 1-2 weeks. Male infertility may be the presenting sign of a serious medical condition Etiologies Congenital Acquired Systemic disorders Hypothalamic-pituitary disease Testicular disease Post-testicular defects Unexplained (40—50%)

Ovarian Neoplasm Classifications: Epithelial cell

Serous Mucinous Endometroid Brenner Clear

Criteria for Severe Preeclampsia

Severe hypertension (systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg) at rest on two occasions at least 4 hr apart* Renal insufficiency (serum Cr >1.1 mg/dL or doubling of baseline values) Cerebral or visual disturbances Pulmonary edema Epigastric or right upper quadrant pain Elevated liver enzymes (AST or ALT at least two times normal level) Thrombocytopenia (platelet count <100,000/µL)

Urinary Catheters When is it indicated?

Short term decompression of urinary retention Chronic retention that cannot be managed medically or surgically Protect wounds that can be contaminated by urine Terminally or severely impaired patients who cannot tolerate garment changes and accepting of risk

Menopause or the climacteric

Signals the termination of reproductive function. End of menses and childbearing There is a massive loss of oocytes over the reproductive years so that only a few primary follicles remain at time of menopause. Most lost due to atresia during reproductive life Loss of functional follicles causes menopause --Level of ovarian steroids fall (E and P) --Gonadotropin levels rise (LH and FSH)

HIV Symptomatic Stage

Signs of Opportunistic Infections begin when CD4 count is <200. CD4 <50 is profound immunosuppression Mortality greatest within 12-24 months. CMV retinitis and disseminated Mycobacterium avium-intracellulare common.

Characteristics of Benign Adenexal Mass

Simple cyst < 10 cm size Septations <3mm thickness Unilateral Calcifications-especially teeth Gravity dependent layering of cyst contents Mobility Consistency Cystic Smooth Unilateral

Proliferative Breast Lesions Without Atypia

Small Increased Risk of Developing Breast Cancer (1-2x the general population) Usual Ductal Hyperplasia Intraductal Papilloma/Multiple Papilloma Sclerosing Adenosis Radial Scars Simple Fibroadenomas

Which of the following raises suspicion for pathologic nipple discharge? Multiple ducts involved Discharge only when compression applied Creamy or white discharge Spontaneous discharge

Spontaneous discharge

General Diagnostic Considerations for all Kidney Stones

Stones must be caught by straining urine, and crystallography performed 24 hour urine collection for volume, pH, creatinine, urea, Na+, calcium, phosphate, urate, oxalate, citrate, and cystine (crystals) Metabolic work up after passage of stone even if no stone caught.

Types of Established UI

Stress Urge Overflow Mixed " Functional" Urinary Incontinence Due to restricted mobility Most older patients also have associated lower urinary tract dysfunction Impaired mobility is likely to be contributing to urinary incontinence rather than the sole cause

Cervical Cancer Treatment Options

Surgery- conization= radical hysterectomy Radiation therapy Complications: Acute Chronic

Managemet of Complete MOLE

Surgical evacuation of tissue (suction currettage) Baseline chest x-ray (to rule out metastasis) Blood TSH and free T4 Serial quantitative HCG until negative Contraception for 1 yr Chemotherapy for persistent gestational trophoblastic tumor as indicated by plateaued or rising quantitative HCG levels

Vulvar & vaginal Cancer Management

Surgical excision 5mm margins Vulvectomy

Surgical abortion

Surgical management with vacuum aspiration (5 to 6 weeks' gestation) or dilation and curettage (6 to 13 weeks' gestation) is preferred over medical abortion in situations where anesthesia may help with anxiety and with pain or when mifepristone is contraindicated Women who present with *septic* abortion need emergency treatment with high-dose antibiotic therapy and surgical evacuation of the uterine contents by an experienced surgeon The greater the availability of temporary and permanent methods of contraception, and the more informed women (and men) become about their safety and acceptability, the less demand there should be for abortion.

When to start Antiretroviral Therapy (ART)

Symptomatic: Without treatment, risk of death within 3-18 months Asymptomatic HIV with CD4 count <200 What about Asymptomatic and CD4 count > 200? Individualized based upon rate of CD4 decline, viral load, and willingness to long term commitment to ART (benefits > risks)

Epididymitis: Sx's, Signs

Symptoms:* Scrotal pain. May radiate to the flank. Fever. Swelling. PE: As above. +Prehns sign * More advanced cases often present with testicular swelling and pain (epididymo-orchitis)

Pregnancy and STI

Syphilis, HIV, chlamydia, and hepatitis B screening *all pregnant women* *Gonorrhea screening*: at-risk pregnant women starting early in pregnancy repeat testing as needed to protect the health of mothers and their infants.

Female Diagnostic Evaluation-Labs

TSH Coagulation Panel (PT, PTT, Factor VIII, Von Willebrand Factor Ag and Activity) Hemoglobin/Hematocrit Gonorrhea/Chlamydia Culture Prolactin Testosterone/DHEAS FSH/LH Liver Function Pregnanacy

Lynch Syndrome II

Tend to have a history of cancer: breast ovarian endometrial gastrointestinal genitourinary Symptoms Gi disturbances Dyspepsia Increased flatulence Bloating Vague pelvic symptoms Usually present with advanced disease-often vague symptoms early-LISTEN TO PATIENTS Routine pelvic exam detect only 1 0f 10,000 asymptomatic women Pap smear NOT diagnostic

If XY and active SRY:

Testes develop, producing testosterone and MIH. MIH causes the Mullerian ducts to regress and Test causes the epididymis, vas deferens, and seminal vesicles to develop. Test is also converted to DHT by 5a-reductase to for the development of the penis, prostate, and scrotum

A painless testicular mass is

Testicular Cancer until proven otherwise. -Orchiectomy -Serum markers (a-Fetoprotein and B-HCG) are useful for follow up

The anthropoid pelvis

The anthropoid pelvis resembles that of the anthropoid ape. It is found in approximately 20% of women and has the following characteristics: A much larger anteroposterior than transverse diameter, creating a long, narrow oval at the inlet Ischial spines that are not prominent but are close, because of the overall shape Narrow, outwardly shaped subpubic arch The fetal head can engage only in the anteroposterior diameter and usually does so in the occipitoposterior position because there is more space in the posterior pelvis.

Histophysiology of the Endometrium

The endometrium is uniquely responsive to the circulating progestins, androgens, and estrogens. It is this responsiveness that gives rise to menstruation and makes implantation and pregnancy possible. Functionally, the endometrium is divided into two zones: The outer portion, or functionalis, which undergoes cyclic changes in morphology and function during the menstrual cycle and is sloughed off at menstruation The inner portion, or basalis, which remains relatively unchanged during each menstrual cycle and, after menstruation, provides stem cells for the renewal of the functionalis.

Primary Dysmenorrhea

The etiology of primary dysmenorrhea has been attributed to uterine contractions with ischemia and production of prostaglandins. Women with dysmenorrhea have increased uterine activity, which results in increased resting tone, increased contractility, and increased frequency of contractions. During menstruation, prostaglandins are released as a consequence of endometrial cell lysis *Associated Symptoms* Nausea and vomiting Fatigue Diarrhea Lower back pain Headache *Treatment* NSAIDs, which act as COX inhibitors, are highly effective in the treatment of primary dysmenorrhea. Typical examples include ibuprofen (400 to 600 mg every 6 to 8 hours) naproxen sodium (250 to 500 mg every 8 hours) *Hormonal contraceptives* Such as oral contraceptive pills (OCs), patches, or transvaginal rings, reduce menstrual flow and inhibit ovulation and are also effective therapy for primary dysmenorrhea.

Vulva

The external genitalia are referred to collectively as the vulva. The vulva includes the mons veneris, labia majora, labia minora, clitoris, vulvovaginal (Bartholin) glands, fourchette, and perineum. The clitoris lies just in front of the urethra Most of the vulva is innervated by the branches of the *pudendal nerve*. The vulva is innervated by the ilioinguinal and genitofemoral nerves. This area is not anesthetized adequately by a pudendal block

Femoral Hernia

The femoral hernia follows the tract below the inguinal ligament through the femoral canal. Frequently become incarcerated or strangulated.

Obstetric Analgesia and Anesthesia

The goal of obstetric analgesia and anesthesia is to provide effective pain relief for the mother during the course of labor and delivery that is safe for her and her baby and that has minimal or no adverse effects on the progress and outcome of labor. Maternal mortality because of anesthesia has decreased to less than 1 in 500,000 mothers. *Options for Labor Pain Relief* Nonpharmacologic methods include education and psychoprophylaxis (Lamaze method), emotional support, back massage, hydrotherapy Pharmacologic treatment options include parenteral narcotics, regional analgesia (epidural, spinal, combined spinal-epidural, paracervical, caudal, and pudendal nerve

The gynecoid pelvis

The gynecoid pelvis is the classic female type of pelvis and is found in approximately 50% of women. It has the following characteristics: Round at the inlet, with the widest transverse diameter only slightly greater than the anteroposterior diameter Ischial spines of average prominence Well-curved sacrum Spacious subpubic arch with an angle of approximately 90 degrees These features create a cylindrical shape that is spacious throughout

Fallopian Tubes

The oviducts are bilateral muscular tubes (about 10 cm in length) with lumina that connect the uterine cavity with the peritoneal cavity. *Segments of the fallopian tubes*: Interstitial portion Isthmus Ampulla Fimbria The mobility of the fimbriated end of the tube plays an important role in fertility. The ampullary portion of the tube is the most common site of ectopic pregnancies

Abdominal Anatomy

The rectus sheath is a strong fibrous compartment formed by the aponeuroses of the three lateral abdominal wall muscles. Each rectus muscle has a firm aponeurosis at its attachment to the symphysis pubis, and this tendinous aponeurosis can be transected if necessary to improve exposure, as in the *Cherney incision*. The *inferior epigastric arteries* arise from the external iliac arteries and proceed superiorly just lateral to the rectus muscles between the transversalis fascia and the peritoneum. In a transverse rectus muscle-cutting *(Maylard) incision*, the epigastric arteries can be retracted laterally or ligated to allow a wide peritoneal incision.

Missed Abortion

The term missed abortion is used when the fetus has died but is retained in the uterus, usually for more than 6 weeks.

Theca Lutein Cysts

Theca lutein cysts typically appear as bilateral cystic masses with multiple septations. They are believed to be caused by an ovarian response to high levels of human chorionic gonadotropin One would likely suspect theca lutein cysts by their typical appearance, although having an appropriate clinical history is helpful in making a more confident diagnosis Looks like gross grapes

Intrauterine Growth Restriction: Placental

This category is representative of circumstances in which there is inadequate substrate transfer because of placental insufficiency. Conditions that lead to this state include essential hypertension, obesity (associated with leptin resistance which leads to placental dysfunction), chronic renal disease, and pregnancy-induced hypertension.

Amnioinfusion

This is the replacement of amniotic fluid with normal saline infused through a transcervical intrauterine pressure catheter, and it has been reported to decrease both the frequency and severity of variable decelerations Common technique is to infuse a bolus of up to 800 mL of normal saline at a rate of 10 to 15 mL/min over a period of 50 to 80 minutes. This is followed by a maintenance dose of 3 mL/min until delivery. Amnioinfusion results in reduced cesarean deliveries for fetal distress and fewer low Apgar scores at birth without apparent maternal or fetal distress

Delivery of the Fetus

To facilitate delivery of the fetal head, a Ritgen maneuver is performed. The right hand, draped with a towel, exerts upward pressure through the distended perineal body, first to the supraorbital ridges and then to the chin. This upward pressure, which increases extension of the head and prevents it from slipping back between contractions, is counteracted by downward pressure on the occiput with the left hand. Once the head is delivered, the airway is cleared of blood and amniotic fluid using a bulb suction device Delivery of the anterior shoulder is aided by gentle downward traction on the externally rotated head. The brachial plexus may be injured if excessive force is used. Delayed cord clamping is recommended for 1 to 2 minutes. *Third Stage of Labor* Immediately after the baby's delivery (the end of the second stage of labor), the cervix and vagina should be thoroughly inspected for lacerations Surgical repair should be performed when necessary, perineal lacerations that continue to bleed require repair.

In menopause the following changes to lipid profile are noted

Total cholesterol increases HDLs decrease LDLs increase Estrogens are noted to have a cardioprotective effect However, HRT should not be offered to patients with the primary goal of protection against heart disease

Second-Trimester Screening

Traditionally, a woman was offered the serum triple screening test that measures α-fetoprotein (AFP), hCG, and unconjugated estriol (UE3) at 16 to 20 weeks' gestation. If the MSAFP level is elevated, an ultrasound should be done to rule out multiple gestation, fetal demise, or inaccurate gestational age (all of which can give false-positive results). If none of these factors are present, amniocentesis is recommended to determine the amniotic fluid AFP leveland to measure acetylcholinesterase

Treatment: Testicular Torsion

Treatment: Immediate surgical repair.* This is a true surgical emergency!!* The duration of testicular ischemia determines the clinical outcome May attempt manual detorsion (like opening a book) Testicular salvage rates are 90-100% if detorsion is done within 6 hours of symptoms. If detorsion occurs > 24 hours, the salvage rate is < 10%.

Etiology of Cervical Cancer: Human Papillomavirus Virus

Types 16 & 18 responsible for 70% of cervical cancer Over 100 types of HPV High Risk Types (16, 18, 31, 33) causes High Grade Lesions and Invasive Cancers Low Risk (6, 11) causes condylomas and Low Grade Lesions Sexually Transmitted Disease

Nervous System Disorders associated with HIV

Ultimately occurs in all untreated HIV patients Mild cognitive deficits/peripheral neuropathy - severe dementia and CNS infections/malignancy. CNS microglia infected early on. *Meningitis/Headaches* Acute/Chronic meningitis: Aseptic, Cryptococcus, TB, coccidioidiomycosis, histoplasmosis *Diffuse Disorders* Dementia Encephalitis: Toxoplasmosis, CMV *Focal Brain Disorders* Toxo, Lymphoma, PML, TB abscess, other abscess *Myelopathies* Sub-acute/chronic, CMV *Peripheral Neuropathies* Sensory Polyneuropathy, toxic-metabolic, CMV *Myopathies* Noninflammatory, inflammatory, AZT PML = Progressive Multifocal Leukoencephalopathy

Infertility: Anatomic Factors

Uterus Uterine abnormalities are usually associated with pregnancy loss Assessment of the uterus is especially important with history of AUB, recurrent pregnancy loss, preterm delivery, previous uterine surgery. What are some potential abnormalities? Fallopian Tubes and Peritoneum The fimbriated end of the fallopian tube picks up the oocyte. The oocyte is transported to where fertilization occurs. Five days after fertilization, the embryo enters the endometrial cavity where implantation occurs.

Erectile Dysfunction Treatment*

Vacuum pump & tension ring-not as effective Self injections (work very well - prostaglandin E1 - doesn't require stimulation), transurethral medication (muse - not highly effective). Unpleasant. Oral medications - Viagra, Cialis, etc. - difference is half lives - still require stimulation. Very effective** -Contraindicated in patients taking NTG. Surgery - bendable rod, inflatable implants - used when oral medications fail.

Vaginal Hysterectomy

Vaginal hysterectomy, if feasible, is preferable to the abdominal approach because it avoids a visible scar, is associated with less pain, affords an opportunity to correct pelvic relaxation, and generally requires less postoperative hospitalization and disability.

Penile CA

Very rare Squamous cell carcinomas of the penis - very uncommon - non-painful Mostly in uncircumcised men* If it has metastasized then it is usually fatal w/in a couple of years HPV increases risk* Anytime there is a lesion on the penis (especially under the foreskin) must consider penile cancer* Tx - treat with antibiotics, see them back in 1 week - if it isn't better yet get a biopsy

Chronic Pelvic Pain Management

When treating patients with CPP, a therapeutic, supportive, and sympathetic (but structured) physician-patient relationship should be established Relaxation, cognitive and behavioral therapies are employed to replace the pain behavior and its secondary gain with effective behavioral responses. Multidisciplinary management has been shown to be more effective than traditional gynecologic management. The personnel should include: a gynecologist a psychologist who also has expertise in chronic pain sexual and marital counseling a physical therapist with pelvic floor muscle expertise and for more complex cases requiring diagnostic or therapeutic nerve blocks, an anesthesiologist or an acupuncturist

Antepartum Management

When ultrasonic findings strongly suggest IUGR, delivery is indicated at gestational ages of 34 weeks or later only if abnormal fetal surveillance indicates an increased risk of fetal death. Assessment of fetal movements (kick counts) Doppler-derived umbilical artery systolic-to-diastolic ratios are abnormal in IUGR fetuses.

Uterine Defects

Women who do not have withdrawal bleeding after a hormonal challenge test and who have a history of uterine instrumentation, particularly a dilation and curettage following vaginal delivery or pregnancy termination, may have Asherman syndrome (AS).

Epidemiology of Cervical Cancer

Worldwide -most common causes of cancer deaths in women United States - NOW 13th most common CA 12,410 cases in 2008 4,008 deaths Rare before age 20, mean age 47

HIV Periodic Evaluations

Yearly FLU vaccine Pneumococcal vaccination: Antibody response to pneumococcal polysaccharide best with higher CD4 (may wish to wait till CD4 count increased before vaccination) Vaccination for Hepatitis B (if serologic negative testing) Periodic evaluation for ongoing medical needs, drug maintenance monitoring, psychological and social needs REDUCE risk factors: safe sex, IV drug use, etc.

Liley Curve: Delta Optical density 450 of amniotic fluid Bilirubin

Zone 1: Very low risk of severe fetal anemia Zone 2: Mild to moderate fetal hemolysis Zone 3: Severe fetal anemia with high probability of fetal death w/in 7-10 days Obsolete test, as not readily available in most commercial laboratories, now that have non-invasive Middle cerebral artery peak systolic velocity

WHARTONS JELLY is

a gelatinous substance within the umbilical cord, largely made up of mucopolysaccharides (hyaluronic acid and chondroitin sulfate). It also contains some fibroblasts and macrophages. [1] It is derived from Extra Embryonic Mesoderm.

Polymenorrhea

abnormally frequent menses at intervals < 24 days

Survival after intrauterine transfusion for Rh sensitivity is

about 85%. Normal neurologic outcomes expected in those who do survive first and subsequent (IVT) transfusions for Hydrops fetalis. Earlier interventions likely when more people covered with insurance. Mat'l donor blood works best for IVT.

Anovulation

absence of ovulation

Ascites And Other Peritoneal Mass

an indirect indicator of malignancy, occurs with peritoneal tumor spread Ascites may allow peritoneal implants to be seen Although a small amount of fluid in the cul-de-sac is normal in premenopausal women, an increased risk of malignancy has been reported if it measures more than 15 mm in anteroposterior dimension

Ovarian Tumor Markers

b-hCG, l-lactate dehydrogenase (LDH), and alpha-fetoprotein (AFP) levels may be elevated in the presence of certain malignant germ cell tumors Inhibin A and B sometimes are markers for granulosa cell tumors of the ovary.

All pregnancies complicated by placenta previa should also be delivered

by cesarean delivery.

Tertiary Syphilis

disappearance of the symptoms of secondary syphilis marked by ulcers in and gummas under the skin Common skeletal, cardiovascular, and nervous systems

Two clinical interventions have been shown to reduce cesarean delivery rates

external cephalic version (ECV) and VBAC.

Infertility:

failure of a couple to conceive after 12 months of frequent, unprotected intercourse. Over the age of 35 years, preliminary evaluations can be attempted after 6 months of attempting conception Conditions that affect fertility are divided into 3 main categories: Female factors (65%) Male factors (20%) Unexplained/other conditions (15%)

hPl (human placental lactogen) ORhCS (human chorionic somatomammotropin)

hCS detected in maternal plasma at 5 wks and rises throughout pregnancy in proportion to the weight of the placenta A protein hormone with similar functions as prolactin (PRL) and (growth hormone) GH (anabolic and lypolytic) Causes decreased insulin sensitivity and decreased glucose utilization in the mother; directs larger flow of glucose to the fetus Stimulates development of mammary glands hCS inhibits maternal glucose uptake, increasing serum glucose. Glucose is a major energy substrate for fetus

High risk sexual behaviors

having multiple current partners having a new partner using condoms inconsistently having sex while under the influence of alcohol or drugs having sex in exchange for money or drugs

Menometrorrhagia

heavy and irregular bleeding

Secondary Syphilis - Clinical Manifestations

hematogenous dissemination of *spirochetes *Usually 2-8 weeks after chancre appears Findings: *rash whole body (includes palms/soles) mucous patches *condylomata lata HIGHLY INFECTIOUS constitutional symptoms Sn/Sx resolve in 2-10 weeks

Torsion results from

inadequate fixation of testis to tunica vaginalis Torsion may occur from an inciting event (trauma) or spontaneously. Often occurs several hours after vigorous physical activity or minor trauma to the area.

Metrorrhagia

irregular episodes of uterine bleeding

Wharton's Jelly

is a gelatinous substance within the umbilical cord, largely made up of mucopolysaccharides (hyaluronic acid and chondroitin sulfate). It also contains some fibroblasts and macrophages. [1] It is derived from Extra Embryonic Mesoderm.

Premature ovarian failure

menopause that occurs < 40 years of age. Testosterone tends to be the major product of the postmenopausal ovary. Estrone is the predominant endogenous estrogen in postmenopausal women. Estrone concentration is directly related to body weight. Androstenedione is converted to Estrone (E1) is proportional to amount of fatty tissue. What effect can estrogen have on the endometrium? Endometrial proliferation. Obese, postmenopausal women have a higher risk of endometrial hyperplasia and uterine carcinoma. Slender, menopausal women are at higher risk for menopausal symptoms.

Placental Functions

metabolism transport of substances endocrine secretion

Premature Ovarian Failure

ovarian failure before the age of 40 years When it occurs in patients younger than 30 years of age, ovarian failure may be caused by a chromosomal disorder. A karyotype should be performed to exclude mosaicism (i.e., some cells bearing a Y chromosome). Other causes of premature ovarian failure include ovarian injury as a result of surgery radiation, or chemotherapy galactosemia carrier status of the fragile X syndrome autoimmunity Patients with premature ovarian failure require hormone therapy (estrogen and a progestin) to reduce the risk of osteoporosis.

Secondary Syphilis -Condylomata Lata

papular lesions located on the folds of moist intertriginous areas coalesce to form flat, wartlike lesions especially around the genitalia and anus. highly infectious plaques develop *Treponema pallidum disseminated. Evolution hypertrophic form a soft, red, mushroom-like mass 1-3 cm in diameter.

Clear Cell Tumor

part of the epithelial-stromal tumors Clear cell carcinomas comprise 2.4% of ovarian epithelial neoplasms < 5% of ovarian carcinomas The mean age of patients with clear cell carcinoma is 57 years The most common epithelial ovarian neoplasm to be associated with paraneoplastic hypercalcemia Has low survival rate

Menopause

permanent cessation of menses after significant decrease of ovarian estrogen production. Evidenced by 12 consecutive months with no menstrual bleeding. Perimenopause: the transition from the reproductive to the nonreproductive years during which ovarian estrogen production may fluctuate unpredictably. Menopause marks the end of a woman's natural reproductive life. Average after of menopause in the U.S. is between 50 and 52.

Placenta Increta

placental villi invade the myometrium

Fecundity

probability of achieving a live birth in one menstrual cycle After 12 months of unprotected intercourse, 85% of couples will achieve pregnancy. 85% of infertile couples who undergo appropriate treatment can expect to have a child.

Fecundability:

probability of achieving a pregnancy in one menstrual cycle Estimated to be 20 - 25% in healthy, young couples

Brenner Tumor

rare type of neoplasm belonging to the surface epithelial-stromal class of ovarian tumors Brenner tumors are solid, clearly delineable growths that range in color from yellow to tan The majority of these tumors are benign but can be malignant

Spermatogenesis

requires about 74 days. Together with transportation, a total of about 3 months elapses before sperm are ejaculated. The average ejaculate contains 2 to 5 mL of semen; 40 to 300 million sperm may be deposited in the vagina, 50-90% of which are morphologically normal.

Lymphogranuloma venereum Signs and Symptoms

self-limited genital papules or ulcers followed by painful inguinal and/or femoral lymphadenopathy --may be the only clinical manifestation at presentation. rectal ulcerations Proctocolitis: rectal pain, discharge, and bleeding especially among patients participating in receptive anal intercourse If left untreated: disfiguring ulceration enlargement of the external genitalia subsequent lymphatic obstruction Treatment Antibiotics/ drainage of infected buboes. Doxycycline 100 mg PO bid for 21 d Erythromycin base 500 mg PO qid for 21 d Doxycycline is the drug of choice in patients who are not pregnant. Pregnant and lactating females should be treated with erythromycin. HIV-positive patients should be treated the same as HIV-negative patients may require prolonged treatment longer resolution of symptoms.

Oligo-ovulation:

sporadic and unpredictable ovulation

Endometroid Tumor

the second most common type of epithelial ovarian cancer, which is the most common ovarian cancer make up about 2 to 4 percent of all ovarian tumors about 80 percent are malignant and represent 10 to 20 percent of all ovarian carcinomas overall five-year survival rate for women with endometrioid carcinoma is 83 percent

Battledore Placenta

umbilical cord has inserted along the edge of the placenta instead of a more central location. ramifications of poor blood circulation, since the edge of the placenta is not quite as rich in blood vessels. However, many times this doesn't affect the baby

Barrier Contraceptives

*Condoms* Only contraceptive to protect against STDs Latex is the only one to protect against HIV *Diaphragm* Needs to be fitted to individual Increased risk for UTIs *Cervical cap* Smaller diaphragm Can cause cervicitis, toxic shock syndrome *Contraceptive sponge* *Spermicide*

Breast Mass Evaluation Biopsy

*Core Needle Biopsy* Solid lesion Large cutting needle Radiographically guided Suitable for histology *Fine needle aspiration* Suitable for cytology Used for cyst evaluation *Open Biopsy* Excisional Incisional

Brest development during pregnancy and after partrition

Estrogen - development of duct system Progesterone - Development of the lobule alveolar system Both E and P suppress milk production lactogenesis: PRL promotes milk production

Antepartum Hemoorhage: Causes Common & Uncommon

*Common* Placenta previa (When the placenta covers the opening in the mother's cervix) Preterm labor (marginal separation of placenta) *Uncommon* Uterine rupture Fetal vessel rupture Cervical or vaginal lacerations Cervical or vaginal lesions Congenital bleeding disorder

Couvelaire Uterus

A life threatening condition in which loosening of the placenta causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity

At present, a number of sonographic parameters are used to diagnose IUGR

(1) biparietal diameter (BPD) (2) head circumference (3) abdominal circumference (4) femoral length (5) amniotic fluid volume (6) calculated fetal weight (7) umbilical artery Doppler Of these, the abdominal circumference is the single most effective parameter for predicting fetal weight because it is reduced in both symmetric and asymmetric IUGR

adnexa

(structures closely related structurally and functionally to the uterus such as the ovaries, fallopian tubes, or any of the surrounding connective tissue)

AIDS Defining Illnesses

* Candidiasis of bronchi, trachea, or lungs * Candidiasis, esophageal * Cervical cancer, invasive * Coccidioidiomycosis, disseminated * Cryptococcus, extra pulmonary * Cryptosporidiosis, chronic intestinal (>1 month duration) * Cytomegalovirus disease (other than liver, spleen, or lymph nodes) * Cytomegalovirus retinitis (with loss of vision) * Encephalopathy, HIV-related * Herpes simplex: chronic ulcer(s) (>1 month duration) or bronchitis, pneumonitis, or esophagitis * Histoplasmosis, disseminated * Isosporiasis, chronic intestinal (>1 month duration) * Kaposi's sarcoma * Lymphoma, Burkitt's * Lymphoma, immunoblastic * Lymphoma, primary, of brain (primary central nervous system lymphoma) * Mycobacterium avium complex or disease caused by M. Kansasii, disseminated * Disease caused by Mycobacterium tuberculosis, any site * Disease caused by Mycobacterium, other species or unidentified species, disseminated * Pneumocystis jirovencii penumonia * Pneumonia, recurrent * Progressive multifocal leukoencephalopathy * Salmonella septicemia, recurrent * Toxoplasmosis of brain (encephalitis) * Wasting syndrome caused by HIV infection

AGE Based Differential for AUB (abnormal menstral bleeding)

*13-18yrs* Annovulation due to Immature HPA Hormone Use Pregnancy PID Coagulation Defect Tumors *19-39yrs* Pregnancy Structural (polyps/fibroids) Annovulation (PCOS) Hormonal Use Hyperplasia Cancer (less common) *40yrs - Menopause* Annovulation due to Decreased Ovarian function Hyperplasia Cancer Atrophy Fibroids

Intrauterine Devices 2 Types MOA Sides

*2 types*: Copper Levonorgestrel *Mechanism of Action* Levonorgestrel: prevents sperm and egg from meeting and thickens cervical mucus for unfavorable environment Copper: spermatoxic, inflammatory environment in endometrium Copper IUD is most effective emergency contraceptive *Side effect* Levonorgestrel decreases menstrual bleeding and dysmenorrhea Irregular menses Amenorrhea Expulsion Uterine perforation Ectopic pregnancy

Acute Pelvic Pain: Gyn Causes

*Adnexal accidents* Ovarian cyst torsion Ovarian cyst rupture Hemorrhagic cyst *Acute infections* Endometritis *Pelvic inflammatory disease/Pregnancy complications* Ectopic pregnancy Abortion *Don't forget non-gyn causes*

Breast Mass - Most Common by Age

*Age < 30 years* Fibroadenoma *Age 30-50 years* Fibroadenoma Fibrocystic changes Usual or atypical ductal hyperplasia Atypical lobular hyperplasia *Age > 50 years* Cyst Ductal carcinoma in situ Invasive cancer

STI Screening CDC recommendations

*All adults and adolescents from ages 13 to 64* tested at least once for HIV. *Annual chlamydia screening*: All sexually active women younger than 25 years older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection *Annual gonorrhea screening*: sexually active women younger than 25 years older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection. *Screening at least once a year for syphilis, chlamydia, and gonorrhea all sexually active gay, bisexual, and other men who have sex with men (MSM). MSM who have multiple or anonymous partners should be screened more frequently for STDs (i.e., at 3-to-6 month intervals). *Anyone who has unsafe sex or shares injection drug equipment tested for HIV at least once a year. Sexually active gay and bisexual men may benefit from more frequent testing (e.g., every 3 to 6 months

DOCUMENTATION-Visual breast exam

*Asymmetry* Contour Bulging *Nipples* Symmetry Inversion Retraction Discharge Crusting *Skin Changes* Dimpling/Retraction Edema Ulcers Erythema Eczema Scaling

Hernias: Physical Findings

*Asymptomatic Hernia*: Swelling at the site. Aching? No pain upon examination Enlarges with increased intra-abdominal pressure. *Incarcerated Hernia*: Painful swelling. Pain with palpation. Vomiting or symptoms of bowel obstruction? *Strangulated Hernia*: Symptoms of Incarcerated hernia with a toxic appearance. Systemic toxicity?

Normal Breast Development (Mammogenesis)

*Birth*: 10 to 12 primitive ductal elements beneath the nipple-aveolar complex *Pre-Pubertal*: Slow and steady growth/ branching. Canalization into ductal structures. *Puberty (10-12yo)*: Anterior Pituitary releases FSH and LH that stimulate ovarian follicle maturation that leads to increased Estrogen.

Normal Micturition

*Bladder smooth muscle (detrusor)* Contracts via parasympathetic nerves (S2-S4) *Urethral sphincter* Proximal urethral smooth muscle contracts via sympathetic stimulation (T11-L2) Distal urethral striated muscle contraction is controlled by somatic stimulation by the pudendal nerve (S2-S4) In women: the musculo-fascia supports and compresses the urethra when abdominal pressure increases

Scabies

*Burrows* intraepidermal tunnel created by the moving female mite serpiginous, grayish, threadlike elevations in the superficial epidermis, ranging from 2-10 mm long 300 million cases yearly *Close contact or sharing of fomites *Treatment* scabicidal agent *Prometherin- 5% cream once *Ivermectin-0.5% cream once

Fertility Awareness Methods

*Calendar methods* Avoid sex during fertile period calculated by menstrual cycles *Basal body temperature method* Ovulation when biphasic pattern of rise of basal body temperature by 0.5 ° - 1 °F *Cervical mucus methods* Change in cervical mucus indicates ovulation

Abruptio Placenta Clinical signs and symptoms Diagnosis Complications Management

*Clinical signs and symptoms*: Can vary significantly May present as vaginal bleeding Preterm labor Back pain Uterine tenderness (pinpoint) Frequent uterine contractions or persistent hypertonus *Diagnosis* Clinical Difficult to diagnose with ultrasound negative u/s does not rule out abruption *Complications* Renal failure Fetal demise Maternal shock Disseminated Intravascular Coagulopathy *Management* Delivery of infant as soon as reasonable Active fluid replacement/ resuscitation if massive maternal bleed Tocolysis contraindicated Can also have concealed bleeding

Diagnostic Tests and Procedures for female incontinence

*Cough Stress Test* The patient is examined with a full bladder in the lithotomy position. While the physician observes the urethral meatus, the patient is asked to cough. *Cotton Swab (Q-Tip) Test* This test determines the mobility and descent of the urethrovesical junction on straining and allows differentiation from anterior vaginal laxity alone. The normal change in angle is up to 30 degrees. In patients with pelvic relaxation and SUI, the change in cotton swab angle ranges from 50 to 60 degrees or more *Postvoid Residual (PVR) Test* This test determines how well the patient empties her bladder. Within 10 minutes of voiding into the toilet, a catheter is introduced into the bladder to see how much urine is left behind. This can also be determined noninvasively by ultrasound. Less than 50 mL is considered normal. *Urethrocystoscopy* Urethrocystoscopy allows the physician to examine inside the urethra, urethrovesical junction, bladder walls, and ureteral orifices. *Cystometry* Cystometry consists of distending the bladder with known volumes of water and observing pressure changes in bladder function during filling. The most important observation is the presence of a detrusor reflex and the patient's ability to control or inhibit this reflex. The first sensation of bladder filling should occur at volumes of 150 to 200 mL. The critical volume (400 to 500 mL) is the capacity that the bladder musculature tolerates before the patient experiences a strong desire to urinate These cystometric procedures allow differentiation between patients who are incontinent as a result of uninhibited detrusor contraction and those who have SUI.

Procedures for CIN - Ablative

*Cryotherapy* No diagnosis No anesthesia Use in CIN I Vaginal discharge *Laser* Destruction of transformation zone by carbon dioxide laser No diagnosis Local anesthesia

HPV treatment Provider-Administered

*Cryotherapy* with liquid nitrogen or cryoprobe. Repeat applications every 1-2 weeks. *Surgical removal* either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery. *Podophyllin* resin 10%-25% in a compound tincture of benzoin *Trichloroacetic* acid (TCA) or Bichloroacetic acid (BCA) 80%-90%

Placental steroid synthesis

*Cytotrophoblasts* (CT layer) Secretes releasing and inhibiting hormones (hypothalamic actions) *Syncytial trophoblasts* (SCT layer) Secretes gonadotropin like hormones (pituitary actions, LH and FSH) Human chorionic gonadotropin (hCG) and human chorionic somatomammotropins (hCS)

Nipple Discharge - Galactorrhea

*Definition*: Milk production more than 1 year after weaning, or in a nulligravid or a menopausal woman *Diagnostic tests* Prolactin, TSH Treat underlying cause if found Trial of bromocriptine *Medications* Antipsychotics

Mucocutaneous disorders associated with HIV

*Dermatologic* Herpes Shingles/Zoster Staph folliculitis Bacillary angiomatosis Molluscum contagiosum Seborrheic dermatitis Psoriasis Candida dermatitis (aka Intertrigo) Kaposi's sarcoma (KS) *Oral* Oral candidiasis (thrush) Limited or extensive Painful swallowing (if esophageal) White, cheesy exudate that can be scraped off. Antifungals Oral hairy leukoplakia White, lichenfied, plaque like lesion, not scraped off. Lateral tongue. Relapse - remits Oral ulcerations: Apthous ulcers. May be HSV. Corticosteroids, antiviral, thalidomide may be used. KS: painless purple, blue, red lesions. Ulcerate

Placenta Previa Diagnosis & Management

*Diagnosis* Between 4% and 6% of patients have some degree of placenta previa on ultrasonic examination before 20 weeks' gestation. When placenta previa is diagnosed in the second trimester, a repeat sonogram is indicated at 30 to 32 weeks for follow-up evaluation. *Management* The goal is to attempt to obtain fetal maturation without compromising the mother's health *Timing of delivery* Placenta previa: 37 wks Placenta accrete/percreta/increta: 34 weeks

AUB-L (LEIOMYOMA) Diagnosis and treatment

*Diagnosis* Physical Exam PUS Sonohystogram/HSG MRI *Treatment* Menopause (Shrink and Symptoms Resolve) Danazol (Androgen) GnRH Agonist (Lupron) Hysterectomy Myomectomy Endometrial Ablation Uterine Artery Embolization (UAE)

HSV: Diagnosis and Treatment

*Diagnosis*: PCR Culture *Serology (Type-specific; Western blot) Goals of management Pain relief Acceleration of healing of lesions Decrease recurrences Prevent transmission *Treatment*: Acyclovir Valacyclovir Famciclovir

Endometrial Ca Patterns of Spread

*Direct extension* Most common Through myometrium to serosa Into cervix and on... *Exfoliation of cells through fallopian tube* Ovaries Viscera Parietal peritoneum Omentum *Lymphatic spread* Pelvic lymph nodes to the para-aortic lymph nodes *Hematogenous spread* Lungs, liver Uncommon

Cervical Cancer Pattern of Spread

*Direct invasion* Cervical stroma Uterine corpus Vagina Parametrium *Lymphatic spread* Pelvic » para-aortic lymph nodes *Hematogenous spread* Lungs, liver, bones

Hernia Diagnosis and Treatment

*Dx*: Most are diagnosed clinically. Imaging studies are not required in the normal workup of a hernia CT scanning or ultrasonography may be necessary to diagnose when there is an inability to obtain a good examination because of body habitus *Treatment*: Immediate reduction* Place the patient supine with a pillow under his or her knees Ice Firm, steady pressure.* Avoid "mushrooming" Consult with a surgeon if: reduction is unsuccessful after 1 or 2 attempts; (do not use repeated forceful attempts) concern exists for a strangulated bowel pt. appears to be toxic. Reduction does not have to be permanent. It's important to know that it is reducible and not incarcerated.

Lower Urinary Tract Symptoms:Nomenclature

*Dysuria*: difficult or painful urination *Nocturia*: Voiding >1 time at night that interrupts sleep, or Nocturnal urine output > 33% of total in older adults, >20% in younger adults *Hesitancy*: difficulty in beginning flow or decreased stream *Frequency*: urinating more than usual without increase in total amount *"Overactive bladder"*: sense of urgency with or without incontinence, often associated with frequency and nocturia

RISKS OF OVARIAN CARCINOMA

*Increased* AGE ANIMAL FAT FAMILY HISTORY INFERTILITY NULLIPARITY OVULATION OVULATORY DRUGE TALC BRCA1(60X) BRCA 2 (30X) HNPCC(13) *Decreased* BREAST FEEDING ORAL CONTRACEPTIVES PREGNANCY VEGETABLE FIBER DIET PROPHYLACTIC OOPHORECTOMY

Primary Syphilis Clinical Manifestations

*Incubation: 10-90 days (average 3 weeks) Chancre *Early: macule/papule turns into erodes *Late clean based, painless, indurated ulcer with smooth firm borders Unnoticed in 15-30% of patients Resolves in 1-5 weeks *HIGHLY INFECTIOUS

General Classification of Hypertensive Disorders in Pregnancy

*Eclampsia* Eclampsia is the presence of new-onset grand mal seizures in a woman with preeclampsia that cannot be attributed to other causes. *Chronic Hypertension* The diagnosis of chornic hypertension requires at least one of the following; known hypertension before pregnancy or the dveloment of HTN before 10 weeks' gestation *Superimposed Preeclampsia* Reserved for those women with CHTN who develop new-onset proteinuria (0.3g/24 hour collection) after the 20th week of gestation. *Gestational Hypertension* This diagnosis is made if HTN without proteinuria first appears after 20 weeks' gestation or within 48 to 72 hours of delivery and resolves by 12 weeks postpartum. This diagnosis can only be made in retrospect—if proteinuria or othe signs of preeclampsia does not occur and blood pressure has returned to normal by the 12th week postpartum.

Gyn Procedures

*Endometrial sampling* Obtaining tissue for histopathology *Colposcopy* Diagnositic Indications: identification of cervical, vaginal or vulvar pathology *Dilation & Curettage (D&C)* Diagnositic Indications: evaluation of endometrium *Hysteroscopy* Diagnositic Indications: evaluate uterine cavity for presence of polyps or tumors

Breast and Hormones

*Estrogen* Development and elongation of ductal tissue *Progesterone* Facilitates ductal branching and lobule-alveolar development *Prolactin* Regulates production of milk protein *Menses* Luteal phase --increased rate of cell proliferation --Increased breast size *Menopause* Total number of lobules is decreased

Etiology & Diagnosis of vaginal prolapse

*Etiology* The pelvic fascia, ligaments, and muscles may become attenuated from excessive stretching during pregnancy, labor, and difficult vaginal delivery, especially with forceps or vacuum assistance. *Diagnosis* Vaginal examination is facilitated by using a single-blade speculum. While the posterior vaginal wall is being depressed, the patient is asked to strain down. This demonstrates the descent of the anterior vaginal wall The preferred method for describing and documenting the severity of POP is the Pelvic Organ Prolapse Quantification (POP-Q) system. The extent of prolapse is evaluated and measured relative to the hymen, which is a fixed anatomic landmark.

Breast changes in Pregnancy By Trimester

*FIRST TRIMESTER* Estrogen-Ductal system expansion HPL, HCG, Prolactin-Increased glandular alveoli (Secrete and store milk) Progesterone-Increased lobule/lobe development Continuation of Stage II Mammogenesis *SECOND TRIMESTER* Further development and enlargement of the duct and lobule system Prolactin (via the anterior pituitary)-triggers glandular production of colostrum Placental Lactogen-Secretion of colostrum *THIRD TRIMESTER* Epithelial cells of the alveoli separate into secretory cells that will produce and release milk *POSTPARTUM* Prolactin and Oxytocin lead to the let down and release of milk.

Preparation for Labor: False labor Cervical Effacement

*False Labor* During the last 4 to 8 weeks of pregnancy, the uterus undergoes irregular contractions that normally are painless. These Braxton Hicks contractions are considered false labor in that they are not associated with progressive cervical dilation or effacement. *Cervical Effacement* Before the onset of parturition, the cervix is frequently noted to soften as a result of increased water content and collagen lysis. Simultaneous effacement, or thinning of the cervix

Lacerations at Birth

*First degree*: a laceration involving the vaginal epithelium or perineal skin *Second degree*: a laceration extending into the subepithelial tissues of the vagina or perineum with or without involvement of the muscles of the perineal body *Third degree*: a laceration involving the anal sphincter *Fourth degree*: a laceration involving the rectal mucosa Cervical lacerations that are bleeding and need repair.

Three phases of the menstrual cycle

*Follicular phase* Begins w/ onset of menstrual bleeding Average ~15 days Most variable part of cycle (9-23 days) *Ovulatory phase* Lasts 1-3 days Culminates in ovulation *Luteal phase* Lasts 13-14 days Ends with menstrual bleeding

Benign Vaginal Conditions: Cystic Masses

*Gartner duct cysts* are the most common of these. They arise from the remnant of the Wolffian duct (mesonephros). They vary in size from 1 to 5 cm and are found on the anterolateral walls in the upper half of the vagina and more laterally in the lower half. Most are asymptomatic and require no treatment. They may be surgically removed when symptomatic. *Bartholin cysts* start with occlusion of the Bartholin duct at the 4 and 8 o'clock positions of the vaginal introitus. The trapped mucinous secretions from the Bartholin gland accumulate and develop into a smooth, skin colored cystic structure ranging from 1 to 5 cm in diameter. *Treatment* of these benign cysts is needed only if the woman is symptomatic (experiences pressure-like discomfort) or if there is a rapid change in the size or character of the cyst. Treatment can be with a Word catheter or by marsupialization

PROM: Management

*General Considerations* An intact amniotic sac serves as a mechanical barrier to infection Intact membranes are not an absolute barrier to infection Management is dictated to a large extent by the gestational age at the time of membrane rupture, although the quantity of amniotic fluid remaining after PPROM may be as important as gestational age in determining pregnancy outcome. Oligohydramnios associated with PROM in the fetus at less than 24 weeks may lead to the development of pulmonary hypoplasia. If PROM occurs at 36 weeks or later and the condition of the cervix is favorable, labor should be induced after 6 to 12 hours if no spontaneous contractions occur. *Conservative Expectant Management* Because the risk of infection appears to increase with the duration of membrane rupture, the goal of expectant management is to continue the pregnancy Ampicillin or erythromycin significantly prolongs the interval to delivery in patients with PPROM. *Outpatient Management* Outpatient management is not recommended Any patient with oligohydramnios is not a candidate for outpatient management.

Cervical Cancer Physical Exam

*General* Weight loss Enlarged lymph nodes Edema of legs Ascites *Pelvic exam* Ulcerative, exophytic, granular, necrotic Friable Discharge *Rectovaginal exam*

Genital Sores could be

*Genital Herpes Chancroid *Syphilis Lymphogranuloma venereum Granuloma inguinale *Painful* Genital herpes simplex Chancroid *Painless* Syphilis Lymphogranuloma venereum Granuloma inguinale

AUB-L (LEIOMYOMA):  Risk Factors:

*Increased Risk*: African American Early Menarche (before 10yrs) Red Meat/Ham Beer *Decreased Risk*: Parity (one or more pregnancy greater than 20wks) Green Vegies Fruit Smoking.

*Endometrial ablation* Indications Contraindications Types

*Indications* Failed medical therapy Poor surgical risk for hysterectomy *Contraindications* to medical treatment Contraindications Endometrial hyperplasia Any gynecologic cancer (absolute) *Types* Laser Electrocoagulation Hydrothermal

Pulmonary Disorders associated w/HIV

*Infections common*: ranging from bacterial to opportunistic. 3-4 fold increase in bacterial: encapsulated S. pneumoniae, H. influenza CD4 200-250 increased risk Check sputum Gram stain and Culture/Sensitivity Treatment based upon sensitivity panel *TB*: MDR and MDX strains Certain geographical areas at greatest risk and certain groups: IVDA, institutionalized *Disseminated Coccidioidiomycosis and Histoplasmosis* Histo often infiltrates skin and bone: biopsies to confirm MDR = Multidrug resistant MDX = Extensively resistant

Tumor Markers

*Inhibin*-a peptide hormone secreted by follicular cells of the ovary and sertoli cells of the testis that inhibits secretion of FSH from the anterior pituitary *α-Fetoprotein*-a secretory product from endodermal sinus tumors that can be measured in serum and serves as a specific tumor marker *CA-125*-a dominant antibody-based biomarker

Inadequate Milk Production Causes:

*Insufficent Breast Tissue* Previous surgeries (Augmentation worse than Reduction) *Delay Progression to Stage II Lactogenesis* Delay in milk production Increased Androgens (Obesity, PIH/PreE, PCOS) Retained POC (Continued elevated Progesterone) Pituitary Insufficiency (Sheehan Syndrome-Decreased Prolactin) Maternal Drugs (Dopamine Agonists)

Treatment of Urinary Incontinence

*Lifestyle changes*: Correct/address underlying medical illnesses, functional impairments, and medications that may contribute to UI Weight loss for moderately obese Avoid caffeine, alcohol; minimize evening intake of fluids In smokers with stress UI: tobacco cessation *Behavioral therapy* Bladder training and pelvic muscle exercise (PME): effective for urge, stress, and mixed UI What: pelvic muscles (not the buttocks, inner thighs) How: 3 sets of 8-10 contractions with goal of 6-8 sec/contraction, 3-4x/week for 15-20 weeks Prompted voiding: used in cognitively impaired patients with with urge incontinence *Drugs* Anticholinergics (urge, overactive bladder, mixed) Oxybutynin Tolterodine Trospium Darifenacin Solifenacin Fesoterodine Β adrenergic agonist (urge, overactive bladder) Mirabegron Antidiuretic Vasopressin*-associated with hyponatremia in older patients *Invasive procedures* Botulinum toxin for refractory urge incontinence Sacral nerve modulation for refractory urge incontinence, retention Pessaries for urge incontinence associated with uterine/bladder prolapse *Surgery* Refractory stress incontinence Sphincter damage

Preparation for Labor: Engagement Lightening

*Lightening* Two or more weeks before labor, the fetal head in most primigravid women settles into the brim of the pelvis. In multigravida, this often does not occur until early in labor. *Engagement* occurs when the widest diameter of the fetal presenting part has passed through the pelvic inlet. In cephalic presentations, the widest diameter is biparietal The *station* of the presenting part in the pelvic canal is defined as its level above or below the plane of the ischial spines. The level of the ischial spines is assigned as "zero" station, and each centimeter above or below this level is given a minus or plus designation, respectively.

BREAST PHYSIOLOGY

*Location* Vertical Axis: Second and sixth ribs Horizontal Axis: Sternal edge and Midaxillary line Tail of Spence (Axilla) *Anatomy* Modified eccrine/sweat gland of the skin located on the anterior chest wall Divided into 15-20 glandular units (Lobes) each has a ductal orifice converging at the nipple (Ductal-Lobular Unit) *Morgani Tubercles* Located around the periphery of the areola. Elevations formed by the opening of the ducts of the Montgomery glands Large sebaceous glands (cross between sweat and mammary) Secrete oils for lubrication and decrease bacterial breeding *Blood Supply* Internal Mammary Artery Lateral Thoracic Artery - 1/3 of supply primarily to the upper outer quadrant *Lymphatic Drainage* Superficial to the Deep Lymphatic plexus in a unidirectional flow 3% to the Internal Mammary LN 97% to the Axially LN

Procedures for CIN - Excisional

*Loop electrosurgical excision procedure (LEEP)* Local anesthesia *Conization (laser or cold knife)* Diagnosis General anesthesia Cervical stenosis and cervical incompetence LEEP- should not be used before identification of cervical intraepithelial lesion that requires treatment Laser decreases cervical stenosis compared to cold knife Pic A - Diagnositic conization performed when the squamocolumnar junction is not fully visualized colposcopically Pic B - Therapeutic conization performed for disease involving the ectocervix and distal endocervical canal

Tocolytics

*Magnesium Sulfate* In the United States, magnesium sulfate is frequently the drug of choice for initiating tocolytic therapy. Magnesium acts at the cellular level by competing with calcium for entry into the cell at the time of depolarization A common minor side effect is a feeling of warmth and flushing on first administration. Respiratory depression is seen at magnesium levels of 12 to 15 mg/dL, and cardiac conduction defects and arrest are seen at higher levels. *Nifedipine* Nifedipine as an oral agent is very effective in suppressing preterm labor with minimal maternal and fetal side effects. *Antibiotic Therapy* The use of prophylactic antibiotics in women with preterm labor may prevent progression from a subclinical infection to clinical amnionitis. Use of Glucocorticoids for Fetal Pulmonary Maturation *Antenatal corticosteroid therapy* The use of steroids for fetal pulmonary maturation reduces mortality and the incidence of RDS and intraventricular hemorrhage (IVH) in preterm infants. Treatment consists of 2 doses of 12 mg of betamethasone, given intramuscularly 24 hours apart, or 4 doses of 6 mg of dexamethasone given intramuscularly 12 hours apart.

Synthesis of sex steroidsin testes and ovaries Names of substrate and intermediates Steps in men and women

*Male female shared pathway*: Start from cholesterol in the mitochondria. Side chain cleavage enzyme produces Pregnenolone which is sent to the smooth ER. 17 alpha hydroxylase; 17, 20 desmotase produce DHEA and/or Androstenediol if 17b-hydroxysteroid dehydrogenase is present. Either of these are converted to Androstenedione from DHEA or Testosterone from Androstenediol by 3b hydroxysteroid dehydrogenase. Those molecules are then converted to Estrone from Androstenedione and Estradiol from test by an aromatase. In the female Estrone and Estradiol are converted to Estriol in the liver. In the male 17b hydroxysteriod dehydrogenase is required. Etheir test or androstenediol is converted to active DHT or Androsterone respectively by 5a-reductase.

Vaginismus

A involuntary contraction of the muscles surrounding the introitus. It may have psychological and/or physical causes, but the contraction makes any vaginal penetration either extremely painful or impossible.

Assessment of Fetal Well-Being

*Maternal Self-Assessment of Fetal Well-Being* A simple technique (kick counting) may be used to assess fetal well-being.The mother assesses fetal movement (kick counts) each evening while lying on her left side. She should recognize 10 movements in 1 hour *Nonstress Test Assessment* The first step in the assessment of fetal well-being is the NST. acceleration in fetal heart rate of 15 beats or more per minute above the baseline for at least 15 seconds *Ultrasonic Assessment* The next step in prenatal assessment is to determine the adequacy of amniotic fluid volume by real-time ultrasonography.

Progesterone Only Methods: MOA Indications

*Mechanism of Action*: primarily thickens cervical mucus making it impermeable *Indications* Breast feeding women Women over age 40 Women with contraindications to estrogen --Hx of DVTs, thromboembolism, stroke, migraines --Endometrial cancer --Breast cancer

Treatment of female incontinence

*Medical Therapy* In postmenopausal women with incontinence, estrogens improve urethral closing pressure, vaginal epithelial thickness and vascularity, and reflex urethral function although paradoxically, estrogen has not been shown to reduce loss of urine. *Physical Therapy* Pelvic floor muscle exercises, also known as Kegel exercises, constitute a proven first-line therapy to improve or cure mild to moderate forms of SUI. Kegel exercises before and after delivery may help patients with postpartum urinary incontinence. *Intravaginal Devices* Larger sizes of pessaries have been used to elevate and support the bladder neck and urethra. They have been shown to be effective for SUI. *Surgical Therapy* Abdominal approach Laparoscopic approach Vaginal approach: The mid-urethral sling is now considered a gold standard for the treatment of SUI. *Bulking Injections* Conventional surgical procedures for incontinence sometimes fail in patients with a diagnosis of urethral ISD. ISD is a subtype of SUI marked by a very poorly functioning urethral sphincter. These patients are treated with a suburethral sling procedure or peri- or transurethral bulking injections to improve urethral function.

Physical Exam Genitourinary:

*Men*: Prostate consistency, masses (cannot tell size by DRE) If uncircumcised, check for phimosis, paraphimosis, balanitis *Women*: vaginal mucosa for atrophy, pelvic support, prolapse Sacral reflexes: --Anal wink --Bulbocavernosus reflex Perineal sensation Clinical test for stress incontinence Phimosis: inability to retract the distal foreskin over the glans penis Paraphimosis: entrapment of a retracted foreskin behind the coronal sulcus Anal wink: instruct the patient to relax his/her perineum, then lightly scratch along the side of the rectum. You should see the anus contract ("the wink"). Bulbocavernosus reflex: lightly squeeze the clitoris in a woman or the glans penis in a man; you are looking for the same reflex anal contraction as in the anal wink. Clinical stress test: ask the patient to cough with a full bladder. Observe for and be ready to catch leakage!

Is incontinence inevitable due to aging?

*No. Age≠ Incontinence* Increased prevalence in older individuals is due to predisposition from age-associated changes, combined with the increased likelihood that they will encounter an additional pathologic, physiologic, or pharmacologic insult Note: Not all precipitants may be due to the lower urinary tract process Example: worsening arthritis of the hips affecting mobility so that patient can no longer control urge symptoms in time before getting to the toilet

Non-Proliferative Breast Lesions

*Not associated with increased risk of breast cancer Simple Breast Cysts Papillary Apocrine Changes Epithelial Related Calcifications Mild Hyperplasia of Usual Type

Patient Evaluation: Pain History What questions do you ask someone with chronic pelvic pain?

*Onset* How did it start Does it change over time *Location* Put a finger on it *Duration* How long does it last *Characteristics* Cramping Aching Stabbing *Alleviating/aggravating factors* What makes it feels better? What makes it feel worse? *Associated symptoms* Gyn: discharge, dyspareunia GI: constipation, diarrhea GU: urinary frequency, dysuria, urgency *Radiation* Does the pain radiate to other places *Temporal* Time of day? Relationship to daily acivities *Severity* On a scale of 0-10 *Physical Exam* Thorough evaluation of abdomen, pelvis Attempt to reproduce and localize pain *Lab evaluations* CBC, UA, STI evaluation *Imaging* Pelvic ultrasound

Preeclampsia/Eclampsia Risk factors

*Pathogenesis of Risk Factors* Because of the resolution of preeclampsia after delivery most attention has been focused on the placenta and the uteroplacental interface. Weight gain and Edema Occurs early with preeclampsia and reflect an expansion of the extravascular fluid compartment *Hypertension* The elevation of blood pressure seen in preeclampsia (especially diastolic pressure) is a result of generalized vasspasm and an increase in systemic vascular resistance.

Diagnosis of Adenexal mass

*Physical Examination* A careful pelvic exam is performed with attention to the ovaries, uterus, bladder and rectum The neck, groin and underarms (axilla) are examined for enlarged lymph nodes The lungs are carefully examined for excess fluid The abdomen is examined for the presence of an enlarged liver, a mass or ascites *Blood and Other Tests* Complete blood count (CBC) Serum liver and kidney function tests Serum CA-125 *Imaging* Ultrasound of pelvis -abdominal is better for larger masses Abdominal and pelvic CT or MRI scans may be obtained in advanced cases. X-rays of the upper gastrointestinal tract (UGI series) may occasionally be done Intravenous pyelogram (occasionally) Barium enema (occasionally) Can tell if mass is: Solid Cystic Bilateral Irregular borders Can provide information regarding ascites Other organ involvement

Opportunistic Infection Prophylaxis

*Pneumocystis (PJP)* CD4<200 or history of thrush Trimethoprim - Sulfamethoxazole TMP-SMX or Dapsone Atovaquone Pentamidine *T.B. Isoniazid sensitive* PPD > 5 mm or prior + without treatment, contact with + person Isoniazid (INH) with Pyridoxine or Rifampin (Rif) and Pyrizinamide (PZI) (use first if INH resistant) *Toxoplasmosis gondii* Positive IgG antibody and CD4 <100 TMP-SMX or Dapsone and pyrimethamine *Mycobacterium avium-intracellulare (MAI or MAC)* CD <50 Azithromycin or Clarithromycin *CMV retinitis* moderately effective in patients with CD4 <50 but benefits must outweigh risks of adverse effects Recurrent HSV-2 infection (acyclovir, famciclovir, or valacyclovir) and recurrent Candida esophagitis (fluconazole) reserved for those with recurrent symptomatic disease

Nipple Discharge-Pathologic

*Signs/Symptoms*: Spontaneous Single duct Gross or occult blood Associated with a mass Persistent *Causes*: Intraductal papilloma Duct ectasia With associated mass consider cancer *Work Up * Localize duct Examine for occult blood Diagnostic mammogram Surgical referral Duct excision Galactography Cannulizing and inserting dye in a single duct *Treatment* Duct excision

HPV treatment Patient-Applied:

*Podofilox* 0.5% solution or gel *Imiquimod* 5% cream *Sinecatechins* 15% ointment Podofilox-binding activity to the enzyme topoisomerase II during the late S and early G2 stage. For instance, etoposide binds and stabilizes the temporary break caused by the enzyme, disrupts the reparation of the break through which the double-stranded DNA passes, and consequently stops DNA unwinding and replication Imiquimod- signals to the innate arm of the immune system/ applied to skin, can lead to the activation of Langerhans cells, which subsequently migrate to local lymph nodes to activate the adaptive immune system/activated by imiquimod include NK cells, macrophages and B-lymphocytes. Sinecatechin- water extract of green tea leaves from Camellia sinensis. 2006 first botanical to be approved by FDA for prescription.

Bacterial Vaginosis

*Polymicrobial clinical syndrome* characterized by loss of H2O2-producing lactobacillus sp. Elevated/ alkaline pH *Most common cause of vaginitis/osis Prevalence varies by population: 5%-25% among college students; 12%-61% among STD patients *Complications*: Premature rupture of membranes, premature delivery, low birth-weight delivery, acquisition of HIV, development of PID, post-operative infections after gynecological procedures *50% asymptomatic *Signs/symptoms when present*: *malodorous (fishy smelling) vaginal discharge *Diagnosis*: Amsel Criteria, vaginal Gram stain, rapid tests *Clue cells *Positive whiff test *pH above 4.5

Breast Lobular Involution

*Post Lactation* Lactogenic hormone deprivation Lack of local triggers Glandular atrophy leading to apoptotic cell death and tissue remodeling *Menopause* Ovarian follicle atresia leads to decreased ovarian estradiol and progesterone Atrophy of glandular elements Decrease in the number of lobules Decrease in the fibrous connective tissue

Gynecologic History

*Present Illness* *Abdominal Pain* *Menstrual History* The menstrual history should include The age at menarche (average is 12 to 13 years) Interval between periods (21 to 35 days with a median of 28 days) Duration of menses (average is 5 days) Character of the flow (scant, normal, heavy, usually without clots) Any intermenstrual bleeding (*metrorrhagia*) should be noted The date of onset of the LMP and the date of the previous menstrual period should be *Contraceptive History* Type of contraceptive method Duration of each contraceptive method *Sexual History* *Review of Systems*

2010 CDC STD Treatment Guidelines: Trichomonas vaginalis

*Recommended: Metronidazole 2gm PO x 1 dose Or Tinidazole 2gm PO x 1 dose Alternative: Metronidazole 500mg PO BID x 7d* *Consider as preferred in HIV-infected women

Posterior & Aprical Vaginal Prolapse

*Rectocele and Enterocele* *Posterior* vaginal defects occur when there is weakness in the rectovaginal septum When difficulties with bowel function and defecation occur, lower posterior vaginal prolapse is likely. *Apical Vaginal Uterine Prolapse* Complete procidentia (uterine prolapse through the vaginal hymen) represents failure of all the vaginal supports Symptoms of POP mainly affect a woman's quality of life.However, significant sequelae of POP can occur in neglected cases of procidentia, which may be complicated by excessive purulent discharge, decubitus ulceration, and bleeding.

Types of Hernia Conditions

*Reducible hernia*: This term refers to the ability to return the contents of the hernia into the abdominal cavity, either spontaneously or manually. *Incarcerated hernia*: An incarcerated hernia is no longer reducible. The vascular supply of the bowel is not compromised. Bowel obstruction is common. *Strangulated hernia*: A strangulated hernia occurs when the vascular supply of the bowel is compromised secondary to incarceration of hernia contents

Preeclampsia/Eclampsia Clinical and Laboratory Manifestations

*Renal Function* Renal blood flow and glomerular filtration rate are significantly lower as a result of afferent vasoconstriction and may eventually lead to damage of glomerular membranes thereby incrsaing the permeability of these membranes to proteins and leading to proteinuria. Proteinuria may occur days or weeks after the onset of hypertension. *Coagulation System* Thrombocytopenia is the most common abnormality The specific combination of hemolysis, elevated liver function test and low platelet levels (HELLP syndrome) is a sign of severe preeclampsia. *Liver Function* In the liver, vasospasm may result in focal hemorrhages and infartctions leading to right upper quadrant or epigastric pain and elevated liver function tests. *Placental Function* Decreased uteroplacental perfusion and ischemia can lead to fetal compromise demonstrated by IUGR, oligohydramios and FHR abnormalities. Extensive placental infarctions can result in abruption. *Central Nervous System Effects* Cerebral vascular resistance is high Concerning signs of CNS involvement and may predict imminent seizures Visual disturbances New onset headache Increased reflex irritability/hyperreflexia

Placenta Previa Risk factors Clinical signs Diagnosis and management

*Risk Factors* Advancing maternal age Multiparity Prior cesarean delivery Smoking *Clinical signs and symptoms* Often none Painless vaginal bleeding *Diagnosis and Management* May occasionally be diagnosed via ultrasound MRI Uterine packing following delivery (25% mortality) Hysterectomy

Nipple Discharge-Physiologic

*SIGNS/SYMPTOMS*: Expressed only with compression Multiple ducts involved *Diagnosis*: CBE Mammogram if over 35 *Treatment*: Resolves when nipple is left alone

LACTOGENESIS (Breast Changes with Pregnancy)

*STAGE ONE (Secretory Initiation)* Second ½ of pregnancy (Approx 28wks) High progesterone levels from the placenta stop further differentiation of breast tissue Small amounts of milk with lactose and casein are secreted after 16wks. *STAGE TWO (Secretory Activation)* Copious milk production after delivery Triggered by rapid decrease in progesterone following delivery of the placenta Requires increased levels of prolactin, cortisol, and insulin

SCREENING-Mammograms Starting and stopping

*STARTING*: AMA & ACOG: Recommend starting routine screening at 40yrs USPSTF: Individualize for women under 50yrs ACP: Recommend against screening for women under age 50. *STOPPING*: ACOG 75yrs and older - consult a physician Canadian Task Force Stop at 74yrs USPSTF Stop at 74yrs

Trichomoniasis vaginalis Incidence and Prevalence

*Sexually transmitted parasite 248 million new cases world-wide in 2005 WHO 2011 Estimated prevalence in US: 3.1% in the general female population (2001-4) Prevalence increases with age Highest rates in AA (13.3%; 95%CI 10-17.7%) Symptoms not predictive 8.7% women from 21 states undergoing testing for GC/CT (N=7593) 2.5-23.2% of adolescents 8.6-38% of drug users MOST TRICHOMONAL INFECTIONS ARE ASYMPTOMATIC!!!

Preterm Labor: Causes

*Socioeconomic Factors* In the United States, the incidence of preterm deliveries in the black population is twice as high as that in the white population. Infection-Cervical Pathway Treatment of bacterial vaginosis has reduced the incidence of preterm delivery. For many years, it has been known that treatment of asymptomatic and clinical cystitis is associated with a reduced incidence of PTB. Short cervices appear to be more common in women who have had prior preterm births and pregnancy terminations Women with a short cervix (between 10 and 20 mm) should receive vaginal progesterone 200 mg daily from 19 to 20 weeks until 36 weeks.

Bethesda Classifications of Pap Smear

*Specimen Adequacy*: Satisfactory for evaluation Unsatisfactory Transformation zone present *Interpretation/Result* Negative for Lesion or malignancy Reactive changes Atrophy Organisms *Epithelial Cell Abnormalities* Squamous Glandular 1. *Squamous Cell*: Atypical Squamous Cells of undetermined Significance (ASCUS) Low-Grade Squamous Intraepithelial Lesion (LISL) (HPV/Mild Dysplasia/CIN I) High Grade Squamous Intraepithelial Lesion (HSIL) (Moderate and severe dysplasia/CIN II &III) Squamous Cell Carcinoma 2.*Glandular Cell*: Atypical Glandular Cells (AGC) Endocervical Adenocarcinoma in situ (AIS)

Vulvar & vaginal Cancer Diagnosis based on Biopsy

*Squamous Cell Carcinoma*- 90 % of vulvular malginancies Bowenoid Type (HPV 16, 18 and 33) Risk Factors; smoking, multiple sexual partners, HIV, early age at first intercourse Verrucous Carcinoma *Melanoma*- 2nd most common *Clear Cell Adenocarcinoma*- in utero exposure to DES and Pagets Disease

Treatment Endometrial Ca based on stage

*Stage 1* E-Lap w/ total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) Peritoneal washings Pelvic lymph node dissection Radiation (vault brachytherapy) *Stage II* Same as Stage I if cervix grossly normal Radical hysterectomy, BSO, staging, external beam radiation *More advanced* - individually based Recurrent Disease 75% in 2 years Vaginal vault - most common Radiation therapy Upper abdomen, lungs, liver High dose progestins or antiestrogens Chemotherapy Follow-up Every 3 months x 2 years Every 6 months x 3 years Then annually

Cervical Cancer Staging

*Staging studies* Biopsies, Cystoscopy, Sigmoidoscopy, Chest and Skeletal xray, IV Pyelography, LFT *Laboratory findings in advanced disease* Anemia, Increased BUN, Increased Creatinine, Abnormal LFT, Hypercalcemia *Surgical Staging* Paraaortic lymph nodes status - single most important prognostic factor If done, usually laparoscopic *PET scan*

Presentation Endometrial Ca

*Symptoms* Abnormal vaginal bleeding (Postmenopausal bleeding is ALWAYS abnormal) Vaginal discharge Signs: Obesity Usually normal --External genitalia --Vagina --Cervix ---Open or firm Uterus --Normal size --Enlarged Note on physical --Chest --Abdomen --Adnexa

Human Placenta

*Syncytiotrophoblasts* line the fetal surface of the intervillous space and interact with the maternal blood supply to secrete placental hormones directly into the circulation. *Decidua* lines the maternal surface of the intervillous space and secretes protein hormones.

Distinguishing conditions responsible for acute scrotal pain

*Testicular torsion* Acute Diffuse pain Negative Cremasteric reflex High riding testis, bell-clapper deformity, profound testicular swelling *Appendiceal torsion* Subacute Upper pole of testis pain Positive Cremasteric reflex Blue dot sign *Epididymitis* Subacute Pain in the Epididymis Positive Cremasteric reflex Epididymal induration and tenderness, with or without swelling, possibly positive urinalysis

Development of male internal genitalia depends on two hormones produced by fetal testis:

*Testosterone*: produced by Leydig cells. Act in paracrine manner to stimulate development of Wolffian ducts into epididymus, vas deferens, seminal vesicle and ejaculatory ducts *DHT*: stimulates development of the prostate, penis and scrotum. *Mullerian-inhibiting hormone (MIH) or anti-mullerian hormone (AMH)*: produced by Sertoli cells. In the absence of testosterone, Wolffian ducts regress and Mullerian ducts become fallopian tubes, uterus cervix and upper 1/3 of vagina. In the absence of appropriate hormonal stimulation, female is the "default" pattern of development

Comparative Changes for neurological disease associated with HIV

*Toxoplasmosis* Multiple lesions Spherical and ring enhancing (CT) Located in the basal ganglia, cortex *Primary CNS Lymphoma* One or few lesions Irregular, weakly enhancing on CT Located in the periventricular area *PML* Multiple lesions Multiple lesions seen on MRI only Located in white matter

Transdermal patch & Contraceptive vaginal ring

*Transdermal patch* MOA: estrogen + progestin Decreased efficacy w/ obese patients => contraindicated if weight is >198lbs *Contraceptive vaginal ring* MOA: estrogen + progestin Barrier Contraceptives

4 Zones of the Prostate

*Transition zone*: accounts for 5-10% of prostate, but majority of BPH and 20% of prostatic adenocarcinoma *Central zone*: 25% of bulk, originating at the ejaculatory ducts. 1-5% of adenocarcinomas originate here *Peripheral zone*: 70% of the prostate, 70% of adenocarcinomas, 90% of all prostatitis *Fibromuscular Stroma*: rarely invaded by adenocarcinoma, can experience BPH

Chancroid- treatment

*Treatment*: Azithromycin - 1 g orally (PO) single dose Ceftriaxone - 250 mg intramuscularly X1 Erythromycin base - 500 mg PO TID 7 days Ciprofloxacin - 500 mg PO BID 3 days Single-dose treatment observed compliance. Ceftriaxone treatment of choice in pregnant women I & D large fluctuant lymphnodes

Molluscum contagiosum

*Virus single or, more often, multiple rounded, dome-shaped, pink, waxy papules that are 2-5 mm umbilicated centrally contain a caseous plug *Self resolution 6-18 months *35% recurrence avoid activities or sports involving physical contact between infected areas of skin and exposed skin of other participants. Treatment Curettage Topical agents

Granuloma inguinale

*chronic bacterial infection* frequently is associated with other sexually transmitted diseases common in the tropics and subtropics Characterized by: intracellular inclusions in macrophages referred to as Donovan bodies. affects the skin and mucous membranes in the genital region results in nodular lesions that evolve into ulcers progressively expand and are locally destructive Treatment: trimethoprim/sulfamethoxazole[ doxycycline. Alternatives include ciprofloxacin, erythromycin, or azithromycin At least 3-week course continued until reepithelialization of the ulcer / signs of the disease have resolved. Nonresponse add an aminoglycoside (eg, gentamicin at 1 mg/kg IV q8h). Relapse of granuloma inguinale may occur up to 18 months after treatment. Erythromycin (congenital malformation)/ doxy and cipro contraindicated pregnancy Macrolide/ Tetracycline/ fluoroquinolones

A 55 year old woman presents with vaginal bleeding which started two months ago. She describes it as intermittent spotting. She went through menopause at age 50. She is married and sexually active. Her last pap was 1 year ago and was normal. 1. What should be included on the differential diagnosis? 2. In addition to a thorough history, physical, and pelvic exam, what study does this patient need? 3. What is the next best step in this patient's care?

1. Atrophy Polyps/Fibroids Hyperplasia Cancer 2. Her EMB (endometrail bx) is Negative. The transvaginal and abdominal ultrasound show no fibroids or polyps, but the endometrial stripe is 12 mm. She continues to have bleeding 3. options no answers were given Observation and reassurance Dilation and curettage Radical hysterectomy Start OCP

Ovarian Cancer Prevelance

1:70 women will develop ovarian cancer and 1:100 women will die of it ovarian cancer is the 4th leading cause of death in U.S. women <5% of women who develop Ovarian CA are BRCA1 positive Although BRCA 1 defects have large rates of Ovarian and Breast CA, its still a relatively low amount of the total patients who develop Ovarian CA Women of 60 to 69 years of age adnexal masses have 12 times the malignancy risk of those aged 20 to 30 yrs

Screening for Cervical CancerPapanicolaou (Pap) Smear: Current Recommendations

21-30= every 3 yrs, no HPV screening 30-65= every 3 yrs if no HPV screen, or every 3-5 yrs with HPV screen HPV Vaccination does not change these recommendations Stop Screening Older than age 65 with prior adequate screening After hysterectomy with removal of the cervix and no prior history high grade lesion or cervical cancer

Nephrolithiasis: General Diagnostic Considerations

70%+ of stones are radiopaque, therefore are visible on flat plate of abdomen. (Good specificity, poor sensitivity) CT scan poor evaluator of stones unless spiral. If spiral is available, then test of choice. Also helpful for hydronephrosis. US reasonable alternative if radiation contraindicated. Helpful for hydronephrosis. Intravenous Pyelogram (IVP) can be helpful but cumbersome due to prep, however uses plain film technology. UA may show WBC's, but hallmark is hematuria, whereas pyelonephritis is opposite.

Nephrolithiasis Prognosis

90% of stones pass spontaneously Stones 4mm or less are likely to pass, 8mm or more , unlikely Stones between 4 & 7mm, 50% pass ECSWL used in proximal third of ureteral or renal pelvis stones, ureteroscopy with basket retrieval or ultrasonic/laser lithotripsy in distal two thirds of ureter Recalcitrant hydronephrosis may require nephrostomies Signs of obstruction (hydronephrosis) when all else fails still may requires surgical intervention/stent placement

Hypercalciuria

>4mg/kg/24hr Increased intake Hyperabsorption (IBD) Any cause of hypercalcemia Familial (hereditary) Low urine output (<1100mL/day) Hyperuricosuria increases precipitation of calcium oxalate and phosphate in urine Increased animal protein intake causes acidic urine increasing Ca+ excretion and increases GFR Hypocitraturia (citrate binds Ca+ & prevents ppt) Reabsorption of citrate is enhanced in proximal tubule with acidic urine Hyperoxaluria from increased absorption, consumption, or increased excretion

First-Trimester Screening

A combination of maternal age, fetal nuchal translucency (NT) thickness and maternal serum-free β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein-A (PAPP-A) are included in the first-trimester screen. Elevated levels of free β-hCG and low levels of plasma protein-A are associated with an increased risk for Down syndrome. Visualization of the nasal bone on first-trimester ultrasound has been shown to reduce the risk for Down syndrome, whereas nonvisualization (absence) has been associated with an increased risk.

Prenatal General Physical Examination

A complete physical examination should be performed on each new patient and repeated at least annually. A body mass index (BMI) should be calculated and recorded. Body mass index is calculated by dividing weight in kilograms (kg) by height in meters squared Less than 18.5 = underweight 18.5 to 25 = normal weight 25 to 29.9 = overweight 30 to 34.9 = class one obesity 35 to 39.9 = class two obesity 40 or greater = extreme obesity

Diagnosis of ED

A diagnosis of erectile dysfunction is made in men who have repeated inability to achieve and/or maintain an erection for satisfactory sexual performance for at least 3 months.* Look for an underlying cause.*

Menstrual History

A good menstrual history is essential because it is the determinant for establishing the expected date of confinement (EDC). Modification of *Nägele's rule* for establishing the EDC is to add 9 months and 7 days to the first day of the last normal menstrual period (LMP). For example: LMP: July 20, 2015 EDC: April 27, 2016 This calculation assumes a normal 28-day cycle

Requirements for Erections

A healthy nervous system that conducts nerve impulses in the brain, spinal column, and penis Healthy arteries in and near the corpora cavernosa Healthy smooth muscles and fibrous tissues within the corpora cavernosa Adequate levels of nitric oxide in the penis. Erectile dysfunction can occur if one or more of these requirements are not met.*

Polycystic Ovarian Syndrome

According to recent guidelines (Rotterdam criteria), PCOS is defined by the inclusion of at least two of the following three features: clinical or biochemical hyperandrogenism oligomenorrhea or amenorrhea polycystic ovaries PCOS affects about 6-10% of women worldwide on the basis of classic PCOS criteria, and even more individuals on the basis of the new Rotterdam criteria It is one of the most common human disorders and the single most common endocrinopathy among women of reproductive age. The hyperandrogenism of PCOS results from an overproduction of male hormones by the ovary and often from the adrenal gland. A common clinical sign of hyperandrogenism in PCOS is hirsutism Hirsutism is less likely in women who have used hormonal contraceptives for prolonged intervals In the long term, the insulin resistance associated with PCOS may lead to an increased risk of cardiovascular disease Women with PCOS also have a 2.7-fold increased risk of developing endometrial cancer.

Factors to be considered in Dating of Pregnancy

Accuracy of the date of the last normal menstrual period. Evaluation of uterine size on pelvic examination in the first trimester. Evaluation of uterine size in relation to gestational age during subsequent antenatal visits (concordance or size-for-dates discrepancy). Gestational age when fetal heart tones are first heard using a Doppler ultrasonic device (usually at 12-14 weeks). Date of quickening (usually 18-20 weeks in a primigravida and 16-18 weeks in a multigravida). Sonographic measurement of fetal length (crown-rump) in the first trimester is most accurate. Serial uterine fundal height measurements should serve as the primary screening tool for IUGR.

Ovarian Cycle: Luteinization & Corpus Luteum Function

After ovulation and under the influence of LH, the granulosa cells of the ruptured follicle undergo luteinization. These luteinized granulosa cells form the *corpus luteum*, which produces copious amounts of progesterone and some estradiol. The normal functional life span of the corpus luteum is about 9 to 10 days. After this time it regresses, and unless pregnancy occurs, menstruation ensues and the corpus luteum is gradually replaced by an avascular scar called a *corpus albicans*.

OCPs: Contraindications

Age >35 + smoker or hx of thromboembolism Breast cancer Liver disease/tumors Migraines HTN CAD CHF Stroke Diabetes mellitus

Female Evaluation-History

Age at Menarche/Menopause? Menstrual Pattern? Severity of Bleeding? (clots/floods) Pain? (Severity/Timing) Past or Family History of Bleeding Disorder? Systemic Disease? Meds? Surgical History? *General Exam* Signs of Excess Weight Thyroid Signs of Insulin Resistance Acanthosis Signs of Hemostatic Ds Petechiae, ecchymosis, pallor, swollen joints *Pelvic Exam* External Vulva, urethra, anus Speculum Mass, laceration, ulcer, discharge, foreign body PAP (Non-Adolescent Only) Bimanual Uterus for size, contour, tenderness Adnexa for masses or pain Bladder for masses or painPain

Factors that do NOT affect menopause

Age of meanarche Number of ovulations or pregnancies Lactation Use of oral contraceptives Race Socioeconomic status

Fournier's gangrene

Aggressive fasciitis of the perineum.* Necrotizing fasciitis is a deep infection of the subcutaneous tissues. -generally occur after trauma or surgery Seen in men with diabetes, urethral trauma or obstruction.* Because fasciitis involves subcutaneous tissues, the skin may appear normal or may have a red or dusky hue. The clue to diagnosis is pain and the presence of subcutaneous swelling.* Occasionally, crepitance is present.* In time, necrosis and dark bullae may develop.* The patient appears more toxic than would be expected from the superficial appearance of the skin.* X-rays may show gas within the tissues. Perineal pain and swelling may antedate the characteristic discoloration of the scrotum and perineum. Treatment: Prompt debridement* of all necrotic tissue is critical to the cure! Broad and repeated dissection in the OR with removal of infected tissue is required.* Broad coverage antibiotics.*

Causes of Erectile Dysfunction

Aging** Diabetes* HTN** Cardiovascular disease** Smoking* Nerve or spinal cord damage* Substance abuse Low Testosterone levels Depression/Anxiety* Medications

Endodermal Sinus Tumor

Aka as yolk sac tumor 10% of malignant germ cell tumors Secretes alpha-fetoprotein which is identifying marker

Assisted Reproductive Technologies

All fertility procedures that involve manipulation of gametes, zygotes or embryos to achieve conception comprise the ARTs. In vitro fertilization (IVF) accounts for > 99% of all ART procedures IVF involves Ovarian stimulation to produce multiple follicles Retrieval of the oocytes from the ovaries Oocyte fertilization in vitro in the lab Embryo incubation in the lab Transfer of embryos into a woman's uterus through he cervix After oocyte retrieval, daily progesterone supplementation is necessary to support a potential pregnancy; if conception occurs, supplementation is continued until at least 10 weeks of gestation. Success rates of IVF depend on the etiology of infertility and the age of the female partner

Hernia Prognosis

All incarcerated or strangulated hernias demand admission and immediate surgical evaluation If strangulation of the hernia is missed, bowel perforation and peritonitis can occur.

Family Planning

All methods of birth control that would typically be prescribed to a woman today are far less hazardous to woman's health than a pregnancy would be. In the US, at least half of all pregnancies are unintended The maternal mortality rate in the US is at its highest point in 15 years. There is currently 1 maternal mortality for 30,000 live births. The mortality rate for health, young, nonsmoking women using oral contracpetives for 1 year is approximately 1 death in 1 million users A first-trimester elective pregnancy termination is safer than a tonsillectomy Providing safe, affordable and effective methods of contraception reduces the rates of abortion. About 85% of sexually active couples having unprotected intercourse for 1 year will experience pregnancy. Pregnancy is not established within the uterus until about 7 days after conception, which itself may not occur for up to 5 to 7 days following intercourse. Half of all conceptions are lost before implantation, and at least 10-15% of established pregnancies spontaneously abort.

HIV Diagnosis and Testing

All persons at risk should be tested i.e. sexually active, IV drug use, partners of infected individuals, etc. All pregnant women should be offered testing Why? Vertical transmission without treatment/breast feeding Discuss what + and - mean Face to face to review positives Assurance, and adherence to treatment, can live asymptomatically for decades Individual needs to inform contacts Set up recurrent follow up visits

Permanent Contraception

Also called sterilization, permanent contraceptive methods are available for both men and women. Vasectomy is a safe, minor, office-based procedure that can be performed on men under local anesthesia in most situations Female permanent contraception is slightly more common in the Unites States, even though vasectomy is a safer procedure. The chance of subsequent pregnancy associated with any of these techniques is low, but if pregnancy should occur, the chance that it will be an ectopic pregnancy is increased to at least 20%.

Noninflammatory CPPS

Also known as *prostatodynia* Typical in young men 20-50 Same sx's as CBP PE negative UA, EPS, culture - and normal DRE Tx same as CBP, but also use Alpha blockers, and antidepressants Heat based tx's are sometimes utilized

Etiology of Recurrent Abortion

Although many factors may result in the loss of a single pregnancy, relatively few factors are present consistently in couples who abort recurrently. Cause and effect relationships in individual patients are frequently difficult to determine. *General Maternal Factors* Infection Smoking and alcohol Medical disorders Maternal age Uterine abnormalities Cervical incompetence *Fetal Factors* The most common cause of spontaneous abortion is a significant genetic abnormality of the conceptus.

What lab test(s) should I order for urinary incontinence?

Always: *Urinalysis* Additional tests based on history and physical exam: Urine culture, chemistry, radiologic studies, etc. Postvoid residual (PVR) is not routinely indicated. However, consider it in these situations: Prior urinary retention Longstanding diabetes Recurrent urinary tract infections Severe constipation Using medications known to impair bladder emptying Marked pelvic organ prolapse or prior UI surgery (women)

Fetal Anemia Dx and Treatment

Amniocentesis: Kleihauer-Betke Cordocentesis Ultrasound: hydrops, MCA doppler flow Intravascular fetal transfusion Preterm Birth

Androgens: Testosterone

Androstenedione: precursor of extraglandular estrogens in men Dehydroepiandrosterone (DHEA) Dihydrotestosterone (DHT) Testosterone produced by Leydig cells of testes In women, adrenals supply much of the androgenic hormone requirement but these do not play a large role until after menopause. Androgens required for libido in women

Prolactinomas: Treatment options: Medical Therapy

Anovulatory patients without tumors demonstrable by MRI and for whom the only issues are prevention of osteoporosis and menstrual cycle regulation may be treated medically with combination hormonal contraceptives. The ergot compounds bromocriptine and cabergoline act as dopamine agonists to reduce prolactin secretion and allow for the restoration of cyclic, physiologic estrogen secretion. Bromocriptine normalizes the secretion of prolactin in about 80% of women with microadenomas, and it restores menses and fertility in over 90%.

Hernias

Approximately 25% of males and 2% of females have inguinal hernias in their lifetimes; this is the most common hernia in males and females Approximately 75% of all hernias occur in the groin; two thirds of these inguinal hernias are indirect and one third direct. Indirect hernias are the most common type of hernia in both men and women (crosses the inferior epigastric arteries through the inguinal canal). Others Epigastric Umbilical Femoral A hernia can become incarcerated and can obstruct bowel. The hernia also can lead to strangulated bowel with a compromised blood supply. Approximately 90% of all inguinal hernia repairs are performed on male

Androgens in the body

Approximately one-half of serum androstenedione originates from the ovaries, whereas the other half arises from the adrenal glands. Most circulating androgens are bound to proteins, such as albumin and sex hormone-binding globulin (SHBG). In the bound form, androgens are biologically inactive, although weak binding of testosterone to albumin allows some of this testosterone to become bioavailable for tissue activity. Testosterone is converted (via 5α-reductase) to DHT, which possesses greater biologic potency.

Breast Density

Areyoudense.org National push for legislation requiring Density reporting on Mammogram results Passed in Nevada If Dense breast tissue is present additional testing may be required - breast ultrasound or MRI.

Gestational Trophoblastic Diseases Types?

Arises from extraembryonic trophoblasts Types include: Hydaditiform mole --Complete --Incomplete Invasive Mole (Chorioadenoma Destruens) Choriocarcinoma Placental Site Trophoblastic Tumor

Management of Patient Uterine Atony

As soon as the fetus has been delivered, an infusion of oxytocin (Pitocin) 10 to 40 U/L IV should be started and maintained during the first 6 hours postpartum. The vagina and perineum should be inspected to rule out any lacerations that could cause excessive bleeding. The placenta should be carefully assessed at delivery to make certain there are no missing cotyledons (lobules of placenta). The uterus should be evaluated by abdominal palpation during the first 1 to 2 hours before transfer to the postpartum unit Analogues of prostaglandin F2α given intramuscularly are quite effective in controlling PPH caused by uterine atony Bimanual compression and massage of the uterine corpus may control the bleeding and cause the uterus to contract. Hysterectomy is a treatment of last resort

HIV Lab evaluations

Baseline HIV RNA (plasma viral load) and CD4 (repeat Q 3-4 months) Baseline CBC and chemistries, LFT, and CXR Baseline PPD (positive > 5 mm. induration) Anergy possible with severe immunosuppression (Anergy panel) Baseline Toxoplasmosis ab., RPR/VDRL, FTA-abs, Hepatitis B & C

Category II (Intermediate/Possible Early Dysregulation) Examples of Category II FHR tracings include any of the following four parameters:

Baseline rate --Bradycardia not accompanied by absent baseline variability --Tachycardia Baseline FHR variability --Minimal baseline variability --Absent baseline variability not accompanied by recurrent decelerations Marked baseline variability Accelerations --Absence of induced accelerations after fetal stimulation Periodic or episodic decelerations Recurrent variable decelerations accompanied by minimal or moderate baseline variability Prolonged deceleration >2 min but <10 min Recurrent late decelerations with moderate baseline variability Variable decelerations with other characteristics, such as slow return to baseline, "overshoots," or "shoulders"

Simple Fibroadenomas

Benign Solid tumors with glandular and fibrous tissue Women 15-35 yrs of age Hormonal influence (Increased with pregnancy and Estrogen) (Decreased with menopause) Only slight increased risk of Breast Cancer if complex, adjacent proliferative disease, or FHx of breast Cancer Most women with fibroadenomas have not increased risk Dx: Core Biopsy/Excision Tx: Remove or F/u in 3-6 months with repeat Breast Ultrasound If symptomatic or increased size must excise.

BREAST EXAM

Best with minimal hormone stimulation (7-9 days s/p onset of menses) *Exam - Visual* 1st: Seated with arms relaxed at sides 2nd: Raise arms over head 3rd: Hands on hips/pressing in *Exam-Palpation (Upright and Supine)* 1st: Regional Lymph Nodes (Sitting) (Cervical, supraclavicular, infraclavicular, and axillary) 2nd: Bimanual Concentric circles, radial, vertical Finger pads Light/Medium/Deep Palpation

Reported risk factors for vasa previa include:

Bi-lobed succenturiate-lobed low-lying placentas pregnancies resulting from in vitro fertilization multiple gestations history of second-trimester placenta previa

Colposcopy

Binocular microscope 3% - 5% acetic acid Evaluate surface epithelium and subepithelial blood vessels Identify transformation zone Biopsy suspicious lesions Endocervical curettage Acetic acid is Vinegar. Transformation - squamocolumnar junction

AUB-O (OVULATORY)Polycystic Ovarian Syndrome

Chronic Anovulation Hyperandrogenism - increased androgen secretion from ovarian theca cells Signs and Symptoms Presents at puberty Obesity Hirsutism Amenorrhea (50%), AUB 30% Insulin resistance PCOS - Diagnosis Hyperandrogenism Oligo/Amenorrhea PCOS by Us Studies U/S - Multiple follicular cysts in ovaries (string of pearls) LH/FSH level >= 3/1 Hyperinsulinemia DHEA > 8000 (adrenal tumor) Testosterone > 200 (ovarian tumor) Prolactin (pituitary tumor) 17-hydroxyprogesterone (Congenital adrenal hyperplasia)

Rh Immune Globulin: Indications & Dosing

Blood type and antibody screen are performed for all pregnant women at their first prenatal visit Women who are Rh-D negative with a negative initial screen should have a repeat screen at 28 weeks. Those women with a negative screen at 28 weeks should receive 300mcg of Rh immune globulin (prophylactically). Those women with a (+) screen should have their antibodies identified. If RhD (-), they should also receive 300mcg of Rh immune globulin All pregnant women who are RhD(-) and who are not sensitized (anti-D-negative) and who experience Spontaneous or induced abortion Ectopic pregnancy Significant vaginal bleeding Amniocentesis Abdominal trauma Cephalic version ...should receive 50-100mcg of Rh immune globulin before 12 weeks' gestation and be administered 300mcg if later than 12 weeks. Rh immune globulin is not necessary for complete molar pregnancies, but is necessary for partial molar pregnancies, where fetal tissue may be present. If exact diagnosis is unclear, 300g should be given. The greatest risk of feto-maternal hemorrhage is at the time of delivery. Rh immune globulin should be given routinely within 72 hours of delivery to all Rh(-) women who delivery an Rh(+) child. Additional Rh immune globulin is indicated if the delivery is complicated by excessive hemorrhage (>30 mL of fetal blood suspected or documented)

Osteoporosis

Bone demineralization is a natural consequence of aging. Estrogen affects the development of cortical and trabecular bone. Bone density decreases at 1 - 2% per year in postmenopausal women. Recommendations: Calcium supplementation: 1200 mg/day for women > 50 years old Weight bearing exercise Vitamin D should also be considered, 600 IU/day (50 - 70 years old) then 800 IU/day

LH and FSH

Both are in the same family as thyroid stimulating hormone (TSH) and human chorionic gonadotropin (hCG) All are glycoproteins with a and b subunits a chains of TSH, hCG, LH and FSH are the same b chain confers specificity Rhythm of GnRH secretion influences rate of expression for genes encoding the a, bLH and bFSH subunits. Differential secretion also affected by other hormonal mediators such as testosterone, estrogen, activin and inhibin.

Preeclampsia Initial Lab Evaluation

CBC Platelet count LDH Coagulation panel Renal studies: BUN, Cr, uric acid, 24 hour urine for protein and creatinine (protein/creatinine ratio) Liver function tests: ALT, AST, bilirubin Fetal evalution: NST, fetal growth

Bacterial Vaginosis Treatment

CDC-recommended regimens: Metronidazole 500 mg orally twice a day for 7 days Metronidazole gel 0.75%, one full applicator (5 grams) intravaginally, once a day for 5 days Clindamycin cream 2%, one full applicator (5 grams) intravaginally at bedtime for 7 days

Chlamydia trachomatis

Clinical Manifestations: Mostly asymptomatic cervicitis, urethritis, proctitis, lymphogranuloma venereum, and *pelvic inflammatory disease *Complications: Potential to transmit to newborn during delivery Conjunctivitis, pneumonia

Chronic Pelvic Pain

CPP refers to pelvic pain of more than 6 months' duration that has a significant effect on daily function and quality of life. As a public health problem, it results in great cost to society in terms of hospital services, loss of productivity, and human misery. Obviously, not all lower abdominal and low back pains are of gynecologic origin. Careful evaluation is needed to distinguish gynecologic pain from that of orthopedic, gastrointestinal, urologic, neurologic, and psychosomatic origin

Calcium Stones (75%)

Calcium oxalate (50%) Calcium phosphate stones require alkaline urine Underlying causes include RTA, hyperparathyroidism, sarcoid, hypervitaminosis D, gastrointestinal disease, malignancy, hyperuricosuria, and hypocitraturia (50% are idiopathic) Iatrogenic causes include loop diuretics, acetazolamide (Diamox) Patient controlled causes include poor fluid intake and increased consumption of Ca+, animal protein, and Na+

MUCINOUS CYSTADENOMA

Can attain a huge size (fill pelvis and abdomen) About 85% are benign Derived from mesothelial cells lining the peritoneal cavity and the the surface of the ovary May be complicated by pseudomyxoma peritonei (benign implants on surface of bowel & peritoneal surfaces) Serious is the same but contains a watery substance as opposed to mucinous

Painless hematuria in older patients is

Cancer until proven otherwise. -Do CT/Cytoscopy

Uric Acid stones

Caused by precipitation of uric acid in the urine Risk factors are low urine output, RTA, hyperuricosuria from overproduction or increased secretion (RTA), acidic urine 15% have hyperuricemia, 80% no uric acid abnormality Stones are radiolucent 75% have hyperacidic urine Tx includes increased volume intake, and alkalinization (6.5-7pH) of urine with po NaHCO3 and diamox at hs The majority of uric acid stones dissolve with effective alkalinization in a few weeks. ECSL

Established UI: Overflow or Impaired Emptying

Causes: 1. Obstruction Men-enlarged prostate Women-urethral surgical scarring or large cystocoele/prolapse kinking the urethra 2. Detrusor underactivity Bladder muscle damage (fibrosis, ischemia) Neuropathy (DM, B12 deficiency, alcohol) Sacral cord/spinal efferent nerve damage (tumor, disc herniation, spinal stenosis, neurologic disease)

Hernia Causes

Causes: Any condition that increases the pressure in the intra-abdominal cavity. including the following: Marked obesity Heavy lifting Coughing Straining with defecation or urination Peritoneal dialysis Family history of hernia

Diagnosis and Management Abruptio Placentae

Clinically, the diagnosis of a placental abruption is entertained if a patient presents with painful vaginal bleeding in association with uterine tenderness, hyperactivity, and increased tone. Abdominal pain and uterine tenderness are present in 66% of cases, fetal distress in 60%, uterine hyperactivity and increased uterine tone in 34%, and fetal death in 15%. Placental abruption is the most common cause of DIC in pregnancy. Hypovolemic shock and acute renal failure as a result of massive hemorrhage may be seen with a severe abruption if hypovolemia is left uncorrected.

Types of Cesarean Delivery

Cesarean deliveries are classified by the uterine incision, not by the skin incision. In the *low transverse cesarean delivery (LTCD)*, the uterine incision is made transversely in the lower uterine segment A LTCD incision is associated with a less than 1% risk of symptomatic uterine rupture in the subsequent pregnancy, although this risk may be higher if labor induction or augmentation is carried out. A classic cesarean delivery carries a 4-7% risk of uterine rupture. *Clasical uterine incision* is a vertical incision through the uterus T-incision is both a low transverse and a classic to create a T

Cesarean Delivery

Cesarean delivery is delivery of the fetus through an incision in the maternal abdomen and uterus. Hospitals offering obstetric services must have the personnel and equipment needed to perform an emergent cesarean delivery within 30 minutes. This is especially true for vaginal births after a prior cesarean delivery (VBAC), where the risk of uterine rupture is higher than in those women who have not had a prior cesarean delivery. Cesarean delivery is the most common major operation performed in the United States today. The rate of cesarean deliveries has increased over fivefold, from 5% of births in 1970 to at least 25-30% of births currently. Increase in C-section rate has been attributed to many factors Assumed benefit to fetus Women postponing childbirth until a later age Relative low maternal risk in general Societal preference Fear of litigation There has been over a 10-fold decrease in perinatal mortality in the United States over the last 40 years concurrent with advances in prenatal, intrapartum, and neonatal care. How much of this improvement has been due to the increased use of cesarean delivery is debatable, with the exception of management of the term breech delivery. With the latter delivery method, perinatal and neonatal mortality and significant neonatal morbidity have been shown to improve from 5.0% for those delivered vaginally to 1.6% for those delivered by cesarean. The overall maternal mortality rate from cesarean delivery is currently less than 1 in 1000, but this is about five times greater than the rate for vaginal delivery. However, recent studies have shown that the maternal mortality rate for an elective cesarean delivery approximates that of vaginal delivery.

Ovarian cycle (Day 1-13) follicular phase

Characterized by recruitment and growth of the 15-20 antral follicles with growth of a dominant follicle until ovulation. No fertilization so regression of corpus luteum. Inhibin, E and P are low. Gonadotroph is released from negative feedback, resulting in an ↑ in FSH secretion. Early follicular phase: the rise in FSH recruits a crop of large antral follicles that begin rapid, FSH dependent growth. They produce low levels of E and inhibin B. Rising E and inhibin B (-) feedback on FSH secretion. Selective increase in LH synthesis and secretion. LH/FSH ratio increases during follicular phase ↓FSH leads to atresia of developing follicles, except one dominant follicle. The largest follicle with the most FSH receptors will survive. Late follicular phase: dominant follicle produces increasing amount of E and inhibin B. High E with little P has (+) effect LH on FSH. Some P from follicle 2-3 days prior to ovulation *Ovulation: Induced by LH surge*

Chromosomal Disorders & Genetic Screening

Chromosomal abnormalities occur in 0.5% of live births, but the incidence associated with spontaneous abortions is much higher and is estimated to be approximately 50%. Women older than 34 years are at increased risk of giving birth to children with autosomal trisomies (e.g., trisomy 21, 13, or 18) *Genetic Screening for Autosomal Recessive Disorders* Carrier screening programs for autosomal recessive disorders have traditionally focused on high-risk populations Sickle cell disease: amongst AA, carrier frequency is 1/10 Cystic Fibrosis: amongst Caucasians, carrier frequency is 1/25 Tay-Sachs: amongst Jews, carrier frequency is 1/30

Uterine cycle: Proliferative phase

Coincides with follicular phase Rising E levels in mid to late follicular phase induce all cell types in the stratum basale to grow and divide. Endometrial lining starts to grow Cell proliferation occurs directly via estrogen receptors (ER) and indirectly through production of growth factors like IGF-1 and VEGF (vascular endothelial growth factor). Arteries become more abundant and uterine glands form E induces expression of P receptors, "priming" the uterus to respond to progesterone during the luteal phase of the cycle

Acute Urinary Retention

Common in men who have prostatic hypertrophy. Often precipitated by use of antihistamines and nasal drops. Pt. is unable to urinate. Bladder becomes distended and palpable Rx: Immediate catheterization! -Leave catheter for 3 days. Alpha blockers -5-alpha-reductase inhibitors are used for very large glands.

Breast PAIN (Mastalgia)

Common in women and occasionally men too Approx 40% of women have occasional breast pain 1.2 to 6.7% of women with breast pain are diagnosed with breast cancer 1/3 are Noncyclic 2/3 are Cyclic (Hormonal)

HIV associated Pneumocystis jirovencii Pneumonia(PJP)

Common life threatening infection Increased risk with CD4 <200 Gradual onset of shortness of breath with dry, non productive cough

Complete vs Partial Mole

Complete: Diploid 46XX or 46 XY Fetal tissue is absent BhCG is HIGH >100,000 Risk for Neoplasm=20-30% Partial: Triploid 69 XXX or 69 XXY Fetal tissue is present BhCG is slightly elevated <100,000 Risk for Neoplasm= <5% Neoplasm= Gestations trophoblastic neoplasm

Radial Scars of the breast

Complex sclerosing lesion Fibroelastic core with radiating ducts and lobules Excision (8-17% may have cancer) No further treatment if excision is negative

Initial Evaluation of HIV Positive

Confirm positivity Complete History and Physical Exam Check oral cavity for ulcers, Kaposi's Sarcoma, thrush, Hairy Leukoplakia, Herpetic ulcers Check fundi for CMV retinitis Check Lymph nodes, spleen, liver span Complete neurological exam: neuropathic changes possible and cognitive changes Follow up evaluations every 3-4 months with focused physicals but be sure to do HEENT and lymph nodes, spleen, and liver.

Granulosa-Thecal Cell Tumors

Consist of granulosa cells and portions of thecal cells Have microscopic Call-Exner bodies Low-grade malignancy potential Produce estrogen-often cause precocious puberty 5% occur before puberty May become large presenting as a ruptured mass

HIV Systemic Manifestations

Constitutional symptoms and Fever of Unknown Origin (FUO) Mucocutaneous diseases Esophageal/Gastrointestinal disorders Genitourinary diseases Nervous system disorders Pulmonary Disorders Wasting syndrome Malignancies Renal Disorders Rheumatologic Disorders

OVARIAN DERMOID CYST

Dermoid cyst (teratoma) : This is an abnormal cyst that usually affects younger women and may grow to 6 inches in diameter It is a type of benign tumor sometimes referred to as mature cystic teratoma This cyst is similar to those present on skin tissue and can contain fat and occasionally bone, hair, and cartilage Surgical excision Cystectomy or Oophorectomy 1-3% malignant transformation especially in postmenopausal women

Recurrent Abortion: Management

Desired pregnancy? Serial HCG Imaging Expectant management Medical management Definitive treatment: D&C Important social questions that affect management decisions

Postpartum -Yeast Infection

Diagnosed Clinically: Breast Pain Hx of infant oral or diaper candidal infection Shiny/Flaky skin of the affected nipple Exclusion of other causes of breast pain such as mastitis Treatment: Topical miconazole or clotrimazole Combo with Mycolog (anti-inflammatory) Remove medication prior to nursing If fissures use topical bacitracin If fails then oral Fluconazole 400mg first day then 200mg per day for 14days. (Safe with BF)

Candida esophagitis

Dysphagia, substernal chest pains. Endoscopy with cultures and biopsies, cytology. If ulcerated, rule out CMV or HSV

The maternal-placental fetal unit

E and P reach levels during pregnancy that are higher than the normal cyclic changes Early hCG rescues the corpus luteum, however the corpus by itself cannot produce the high levels necessary to maintain pregnancy. The mother, placenta and fetus work together to maintain appropriate E and P levels Initially the mother contributes most of the cholesterol for steroid synthesis Placenta cannot make its own androgens so must get exogenous DHEA Initially DHEA comes from adrenals of mother As pregnancy progresses, more DHEA derived from fetus from the adrenals and liver

External Cephalic Version

ECV converts a breech fetus to the vertex position to avoid a cesarean delivery for breech presentation. At what gestational age would you perform ECV? What details would you want to know before you attempted ECV? The success rate of ECV is about 60%.

Continuous Electronic Fetal Heart Rate Monitoring

EFM during labor was developed to detect FHR patterns frequently associated with delivery of infants in a depressed condition. It was reasoned that early recognition of changes in FHR patterns that are associated with hypoxia and umbilical cord compression would serve as a warning that would enable a physician to intervene and prevent fetal death or irreversible brain injury. The focus of EFM has been on the recognition that hypoxia leads to a greater risk of acidosis *Uterine contractions* result in a reduction in blood flow to the placenta, which can cause an interruption in fetal oxygenation and lead to corresponding alterations in the FHR. *Internal monitoring* is carried out by placing a spiral electrode onto the fetal scalp to monitor heart rate and inserting a plastic catheter transcervically into the amniotic cavity to monitor uterine contractions To carry out this technique, the fetal membranes must be ruptured and the cervix must be dilated to at least 2 cm.

Ovarian cycle: luteal phase

Early luteal phase: initial ↓ in E. This terminates (+) feedback on LH. As corpus luteum matures levels of E and P rise again. ↑ in P and E leads to (-) feedback on both LH and FSH. Late luteal phase: CL starts to regress, leads to ↓ in P and E. No fertilization so regression of corpus luteum. Inhibin, E and P are low. Gonadotroph is released from negative feedback, resulting in an ↑ in FSH secretion. Menses occurs and cycle repeats

Management of Eclampsia

Eclampsia is a true obstetric emergency Pharmacologic stabilization with magnesium sulfate Eclamptic seizures often induce fetal bradycardia that usually resolved after maternal stabilization Once mother is stabilized, delivery should be expedited *Sequelae and Outcomes* Women with a history of preterm severe preeclampsia are at a 40% risk of recurrent preeclampsia. Pre-pregnancy lifestyle interventions show benefit as does low-dose aspirin The female offspring of women with pre-E experience an increased risk in their own pregnancies

History of Urinary incontinence

Elicit specific symptoms: onset (established vs. transient), frequency, volume, timing; amount/types of fluid intake Established? Stress Urge Overflow Mixed Transient? "DIAPPERS" Red flag symptoms: Abrupt onset Pelvic pain Hematuria Identify associated factors: bowel & sexual function, medical conditions, medications, access to toilets Establish goals of care and impact on quality of life: patient's and caregiver's goals (e.g. complete continence? fewer pad changes?)

Diagnosis Endometrial Ca

Endometrial Biopsy: Sample endometrial tissue Postmenopausal bleeding > 45 years old with irregular bleeding Diagnostic accuracy 90%

AUB-A (ADENOMYOSIS)

Endometrial glands and stroma in the Uterine musculature (ectopic endometrial tissue) Can lead to hypertrophy and hyperplasia of surrounding myometrium Leads to a diffusely enlarged uterus (Globular) Risk Factors: Parous History of Prior Uterine Surgeries Signs/Symptoms: Menorrhagia Dysmenorrhea Chronic Pelvic Pain

Benign Conditions in Which CA-125 Has Been Found to Be Elevated:

Endometriosis Peritoneal inflammation, including pelvic inflammatory disease Leiomyoma Pregnancy Hemorrhagic ovarian cysts Liver disease

Mechanisim of Labor 7 Cardinal movements of labor:

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

AUB-E (ENDOMETRIAL)

Enometritis PID Retained Products of Conception

Erectile Dysfunction

Erectile dysfunction (ED), also known as impotence, is the inability to achieve or sustain an erection for satisfactory sexual activity.* ED varies in severity; some men have a total inability to achieve an erection, others have an inconsistent ability to achieve an erection, and still others can sustain only brief erections. By age 45, most men have experienced erectile dysfunction at least some of the time

Estrogens

Estradiol 17b Estrone estriol Produced by granulosa and thecal cells of ovary Progesterone produced by corpus luteum and later placenta

Risks of Hormone Replacement Therapy

Estrogen + progesterone compared to placebo resulting in an increased risk of Heart attack Stroke Thromboembolic disease Breast cancer Produced a reduced risk of Colorectal cancer Hip fracture Estrogen alone showed that these women had... No increased cardiovascular risk Trend toward a decrease in breast cancer when compared to women taking E+P

Genital differentiation Common tissues Male and female specific

External genitalia of both genders begins to differentiate at ~ 9 - 10 wks gestation The common linage for the genitalia differentiate based on the presence of dihydrotestosterone (DHT) Rxn: testosterone to DHT by 5a-reductase Common tissues: Genital tubercle Genital swelling Urethral folds Urogenital sinus Female (no DHT): Clitoris Labia majora Lower vagina Labia minora Male (DHT present): Glans penis Scrotum Penile shaft Prostate gland

Sertoli cell: expresses

FSH receptor. Stimulates protein synthesis of "nursing" function of cell Synthesis of inhibin. Inhibin B exerts neg. feedback on FSH production

Partial Hydatiform Mole

Fertilization of an ovum by two sperm resulting in triploidy, 69XXX or 69XXY Some fetal tissue present Focal trophoblastic hyperplasia without atypia May rarely occur as a twin pregnancy with the other fetus as normal Risk of progression to trophoblastic tumor is less than 5% Uterus normal or small for dates Less symptomatic, more often presenting like a missed abortion Rarely lead to serious medical complications or progress to gestational trophoblastic tumor

Fertilization

Fertilization, or conception, is the union of male and female pronuclear elements. Conception normally takes place in the fallopian tube, after which the fertilized ovum continues to the uterus, where implantation occurs and development of the conceptus continues. Fewer than 200 sperm achieve proximity to the egg. Ova are usually fertilized within 12 hours of ovulation. Following penetration of the oocyte, the the male pronucleus, fuses with the female pronucleus to form the zygote. Fertilization restores the diploid number of chromosomes and determines the sex of the zygote. Following fertilization, cleavage occurs. This consists of a rapid succession of mitotic divisions that produce a mulberry-like mass known as a morula. The embryo at this stage of development is called a blastocyst.

HIV Constitutional Symptoms

Fevers, night sweats, anorexia, weight loss, or diarrhea not uncommon with profound immunosuppression. May last weeks - months before the development of identifiable OI. Most persistent fevers relate to an identifiable OI. Most common cause of FUO and anemia with a CD4 <50 is MAI: bone marrow biopsy and blood cultures. Need to rule out non-Hodgkin's Lymphoma (possible splenomegally and lymphadenopathy SO biopsy)

Formation of estrogen

Granulosa cells, like Sertoli cells, provide a protective nursing function and express FSH receptor. Thecal cells, like Leydig cells, are outside the "nurse cells", express the LH receptor and produce androgens. However, granulosa cells lack the enzyme (17a-hydroxylase, and 17,20-desmolase) for conversion to androstenedione, so they cannot make testosterone or estrogen without the theca cell. Only one cell required for formation of progesterone

HPV Testing

HPV-DNA High risk types - 16,18,31,33,35,39,45,51,52,56,58,59,68 Sensitivity (98%), Specificity (73%-94%) Women older than 30 should be screened To be used in combination with Pap Will help influence clinical decision making 21-30 reflex HPV testing

A diagnosis of AIDS is made whenever a person (13 years old and older) is HIV-positive and:

Has a CD4+ cell count below 200 cells per micro liter , or CD4+ cells account for fewer than 14 percent of all lymphocytes OR That person has been diagnosed with one or more of the AIDS-defining illnesses.

Human Papilloma Virus (HPV)Risk Factors

Having these risk factors increases the chance that HPV will develop into cancer Multiple sexual partners or partner with multiple sexual partners Immunosuppression Lower socioeconomic status History of STDs Young age at first pregnancy/coitus Smoking

2010 CDC STD Treatment Guidelines Chlamydia/NGU

Recommended: *Azithromycin (macrolide) 1gm po x 1 Or/ and *Doxycycline (tetracycline) 100mg po BID x 7d Alternative: Erythromycin base 500mg po QID x 7d Or Erythromycin EES 800mg po QID x 7d Or Levofloxacin 500mg po qd x 7d Or Ofloxacin 300mg po BID x 7d

Genetic Counseling

Ideally, couples should receive preconception counseling before they decide to have children, so that genetic disease in the couple or their families may be identified. current clinical guidelines recommend that genetic counseling and invasive prenatal diagnostic testing for chromosomal abnormalities be offered to all couples regardless of maternal age. Who would you encourage testing? A previous child with or a family history of birth defects, chromosomal abnormality, or known genetic disorder A previous child with undiagnosed mental retardation A previous baby who died in the neonatal period Multiple fetal losses Abnormal serum marker screening results Maternal conditions predisposing the fetus to congenital abnormalities Teratogenic exposure: drugs, infections or radiation A fetus with suspected abnormal ultrasonic findings A parent who is a known carrier of a genetic disorder

Recognition of the At-Risk Pregnancy (RhD)

If RhD(-) patients whose anti-D antibody titers are positive (those hwo are RhD-sensitized), the RhD status of the father of the baby should be determined. If the father is RhD(-), the fetus will be RhD(-) and hemolytic disease will not occur, so further monitoring is not necessary. If the father is RhD(+), his Rh genotype should be determined using quantitative PCR. If he is homozygous for the D antigen, the fetus will be RhD(+) and potentially affected. If the father is heterozygous, the fetus has a 50% chance of being RhD(+), indicating the need for fetal RhD genotyping.

MANAGEMENT of adenexal tumors

If asymptomatic, normal exam, simple cyst on U/S, normal CA 125 unilateral, 5 cm follow with serial U/S and CA-125 q 3-6 months until 12 months, then annually thereafter If asymptomatic except complex appearance and 5 cm repeat U/S and CA-125 in 4 weeks Persistence or decreasing complexity follow q 3-6 months with U/S and CA-125 Increasing CA-125 or increasing complexity surgery, if complex, 5 cm, and elevated CA-125 take it out If symptomatic, 5 cm, clinically apparent, non-simple in appearance, or elevated CA-125 take it out

HPV and smoking

Impaired antibody response in younger women smoking has been found to prolong the cervical HPV infection resulting in development cervical dysplasia progression of dysplasia towards higher grades of cervical intra-epithelial neoplasia invasive carcinoma Impaired antibody response in younger women/Smoking has been found to prolong the cervical HPV infection resulting in development of cervical dysplasia, progression of dysplasia towards higher grades of cervical intra-epithelial neoplasia and ultimately, invasive carcinoma

MRI of the breast

Improved detection of abnormalities Primarily used for: Screening in BRCA carriers or relatives Evaluation of contralateral breast in breast conservation Very dense breasts Hx of free silicone implants

Incomplete Abortion

In addition to vaginal bleeding, cramp-like pain, and cervical dilation, an incomplete abortion involves the passage of some of the products of conception, often described by the woman as looking like pieces of skin or liver.

Complete Abortion

In complete abortion, after passage of all the products of conception, the uterine contractions and bleeding abate, the cervix closes, and the uterus is smaller than the period of amenorrhea would suggest. Ultrasound can be used to assess the presence of retained placental tissue if excessive bleeding continues. In addition, the symptoms of pregnancy are no longer present, and the pregnancy test becomes negative.

Chemotherapy for adenexal masses

In most cases, chemotherapy is begun one to four weeks after surgery. The standard regimen includes carboplatin or cisplatin + Taxol given intravenously every three to four weeks as tolerated for at least six cycles Carboplatin is now being used more often than cisplatin because it can be given on an outpatient basis Another technique known as intraperitoneal (intra-abdominal) chemotherapy has been developed to deliver the chemotherapy directly into the abdominal cavity and is given monthly for 6 months

Fetal Evaluation during Labor

In patients with no significant obstetric risk factors, the fetal heart rate should be auscultated or the electronic monitor tracing evaluated at least every 30 minutes in the active phase of the first stage of labor And at least every 15 minutes in the second stage of labor. In patients with obstetric risk factors, the fetal heart rate should be auscultated or the electronic monitoring tracing evaluated at least every 15 minutes during the active phase of the first stage of labor (immediately following a uterine contraction) and at least every 5 minutes during the second stage. For high-risk pregnancies, uterine contractions should be monitored continuously along with the fetal heart rate. *Vaginal examination* In the active phase, the cervix should be assessed approximately every 2 hours to determine the progress of labor. *Amniotomy* The artificial rupture of fetal membranes may increase uterine activity

Management of CIN (cervical intraepithelial neoplasia)

In the Coloposcopy you see CIN I= Observation CIN II-III= Ablation of LLETZ CIN II-III & microinvasive or high grade ECC= Cone biopsy/LLETZ Invasive Cancer= Radical Surgery and Radiation LLETZ Large Loop Excision of The Transformation Zone

Inevitable Abortion

In the case of inevitable abortion, a clinical pregnancy is complicated by both vaginal bleeding and cramp-like lower abdominal pain. The cervix is frequently partially dilated, contributing to the inevitability of the process.

Hyperandrogenic Disorders Treatment

In the rare instance of an ovarian or adrenal neoplasm, surgical removal of the tumor is indicated In patients with Cushing syndrome, treatment is surgical removal of the source of excessive cortisol or ACTH secretion (adrenal or pituitary tumor). The initial therapy for hirsutism in patients with PCOS usually begins by suppressing ovarian androgen production with a combination oral contraceptive containing estrogen and a progestin. A peripheral antiandrogen can be added to oral contraceptive therapy to treat hirsutism, regardless of the source of the excessive androgen. The antiandrogen most commonly used to treat hirsutism in the United States is spironolactone. To obtain good cosmetic results, some local hair removal is usually required in addition to medical therapy. Medical management of abnormal vaginal bleeding or endometrial hyperplasia consists of estrogen-progestin oral contraceptives, cyclic or continuous oral progestins

Estrogen's role during pregnancy

In uterus: Stimulates growth of uterine muscle Softens pelvis along with relaxin Causes enlargement of external genitalia Increases duct system of breasts Augments P synthesis Stimulates placental conversion of cortisol to cortisone

Prevention of Calcium Stones

Increase fluid and fiber intake Reduce Na+ and animal protein intake Restrict tea, cola, juices, spinach, kale, legumes, and peanuts (hyperoxaluria) Restrict loop diuretics and Diamox Use Thiazide diuretics to increase distal tubular reabsorption of Ca+ Mg+ and Ca+ supplements bind oxalate in the gut in hyperoxaluria, otherwise decrease intake of Ca+. Potassium/magnesium citrate supplementation for hypocitraturia Treat underlying cause

Mild Hyperplasia of Usual Type in breast tissue

Increase in number of epithelial cells in a duct that is more than two but not more than four cells depth. The cells do not cross the midline.

Obesity and endometrial ca

Increased aromatization of androestenedione to estrone 21-50 pounds overweight 3 x risk >50 pounds overweight 10 x risk

Abruptio Placenta Risk Factors:

Increasing maternal age Increased parity Ethnicity (AA and cauc 1 in 200 vs Asian 1 in 300 and Latin-American 1 in 450) Hypertension Preterm premature rupture of membranes Cigarette smoking Cocaine Abuse Thrombophilia External trauma Uterine Leiomyoma Cocaine Trauma Maternal hypertension Preterm premature rupture of membranes Multiple gestation Polyhydramnios Inherited or acquired thrombophilia Uterine malformations or fibroids Placental anomalies Previous abruption Increasing parity Maternal age

Induction and Augmentation of labor

Induction of labor is the process whereby labor is initiated by artificial means In the case of high-risk pregnancies, induction is necessary to reduce the risk of morbidity to the mother and her fetus. In general, induction of labor is not used for the convenience of the mother or her family, and it should not be done before 38 weeks' gestation because of the possibility of neonatal morbidity. Augmentation is the artificial stimulation of labor that has begun spontaneously Several mechanical and pharmacologic approaches may be used to promote cervical ripening before the actual induction of uterine contractions. Currently approved pharmacologic treatments include intravaginal application of prostaglandin E2 using a vaginal insert (on a string) called *Cervidil*, which can be removed quickly if the medication causes hyperstimulation. *Cytotec*, a synthetic prostaglandin E1 analogue is another available method prostaglandin administration has been demonstrated to shorten the duration of labor induction Other methods of cervical ripening may include intrauterine placement of a Foley catheter into the cervix and inflation of the balloon with 10 cc of saline In addition to cervical ripening, induction of labor requires the initiation of effective uterine contractions. Oxytocin is identical to the natural pituitary peptide, and it is the only drug approved for induction and augmentation of labor. It is helpful to assess the likelihood of success by a careful pelvic examination to determine the Bishop score Continuous electronic monitoring of the fetal heart rate and uterine activity is required during induction.

Prostatitis (General Considerations)

Inflammation of the peripheral zone of the prostate due to infection, trauma, or stasis Palpable on rectal exam (pain, bogginess) Frequently shows bacteriuria on end catch urinalysis Can cause urethral discharge or obstruction of the lower urinary tract Difficult to culture, prostatic massage (digitally Expressed Prostatic Secretions) UA Causes increased PSA blood levels Frequently becomes chronic especially in conjunction with BPH Number 1 urologic Dx in men < 50 Number 3 urologic Dx in men > 50

Approach to UI Evaluation

Keep it simple! 1. Are there reversible causes? 2. If established, what is the mechanism? Can't hold it: Detrusor overactivity (DO) Impaired sphincter function/support Can't empty it so it overflows: Obstruction Detrusor underactivity Combination Restricted mobility

Two cell, two-gonadotropin hypothesis for formation of estrogens.

Neither granulosa or thecal cell alone can make estrogen Steps in estrogen formation LH stimulates theca cells (via cAMP) to increase synthesis of LDL and HDL receptors and side-chain cleavage enzyme. Theca increases its synthesis of androstenedione Androstenedione freely diffuses to granulosa cells FSH (via cAMP) stimulates granulosa cell to produce aromatase Aromatase converts androstenedione to estrone and 17b-HSD converts estrone to estradiol. Estradiol diffuses into blood vessels *FSH induces expression of LH receptors on granulosa cells in late follicular phase. This allows granulosa cells to maintain high levels of aromatase as FSH falls and also ensures that cells will respond to the LH surge*

Leydig cell: expresses

LH receptor. hydrolysis of cholesterol esters and expression of StAR (a protein that transfers cholesterol to inner mito membrane), overall increase in testosterone

Which studies should be done on pts. w/ ED?

Lab testing - check for diabetes, full chemistry panel*, hormone levels (free testosterone - because free testosterone can be treated if it is low).* If penile dysfunction is vasculogenic it generally indicates cardiovascular disease (because they are usually linked)* UA* Lipid panel* PSA* Consider psychosocial evaluation

PTB Management and Delivery

Labor and Delivery of the Preterm Infant With modern neonatal care, the lower limit of potential viability is 24 weeks or 500 g, although these limits vary with the expertise of the neonatal intensive care unit. With a vertex presentation, vaginal delivery is preferred For the breech fetus estimated at less than 1500 g, neonatal outcome is improved by cesarean delivery.

Labor & Delivery

Labor is defined as progressive cervical effacement and dilation resulting from regular uterine contractions that occur at least every 3 minutes and last 30 to 60 seconds each. The fetal head is the largest and least compressible part of the fetus. Thus, from an obstetric viewpoint, it is the most important part, whether the presentation is cephalic or breech The cranial bones at birth are thin, weakly ossified, easily compressible, and interconnected only by membranes. These features allow them to overlap under pressure and to change shape to conform to the maternal pelvis, a process known as *molding*.

Pharmaceutical Abortion

Legal issues concerning the availability of abortion, the conditions under which consent for the procedure must be obtained, and governmental regulations of specifics of the procedure frequently change, and they vary from state to state. Some areas of the United States lack readily available abortion services. From a medical standpoint, abortions are low-risk procedures with few serious adverse outcomes. Before 49 days' gestational age, or with early failed pregnancies, both medical and surgical treatments are available. *Mifepristone* 200 mg followed by misoprostol can induce complete abortion in 96-98% of pregnancies before 42 days' gestational age

Benign Vulvar Conditions

Lichen sclerosus Vaginal atrophy Eczema Psoriasis Crohn's disease Traumatic ulceration

Indications for Colposcopy

Persistent (ASC-US) or ASC-US with positive high-risk human papillomavirus (HPV) subtypes ASC suggestive of high-grade lesion (ASC-H) Atypical glandular cells (AGC) Low-grade squamous intraepithelial lesions (LSIL) High-grade squamous intraepithelial lesion (HSIL) Suspicious for invasive cancer Malignant cells present

Epididymitis

Most common cause of scrotal pain in adults in the outpt setting. Most cases of acute epididymitis are infectious. -caused by retrograde bacterial spread from the bladder or urethra. Route of infection is probably via the urethra to the ejaculatory duct, then down the vas deferens to the epididymis. Several factors may predispose post-pubertal boys and men to develop chronic epididymitis, including sexual activity, heavy physical exertion, and bicycle or motorcycle riding Infectious epididymitis can present as an acute (<6 weeks) or chronic (≥6 weeks) condition. A chronic presentation of infectious epididymitis is more typical, with an otherwise healthy male complaining of scrotal pain. They can be divided into one of two categories based on patients' age. 1)Under 40 yrs. old: typically sexually transmitted.* - Associated with urethritis and result most commonly from Chlamydia or N. gonorrhea. 2)Over 40 yrs. more often associated with UTI and prostatitis,* caused by gram-negative rods.

AUB-L (LEIOMYOMA)

Most common pelvic tumor *Benign* -Arising from smooth muscle cells of the myometrium Reproductive Age Women *Location*: Intermural (middle of uterus muscle), Submucosal (just below inner surface), Subserosal (just below the outer surface), and Cervical. *Signs/Symptoms: Menorrhagia Pelvic Pain/Pressure Infertility *Not Inter-menstrual or PMVB*

Vulvar Ulcerations

Most ulceration in the vagina is associated with acute infections, such as herpes simplex or cytomegalovirus.

Vulvar disease

Most vulvar epithelial lesions present with symptoms of pruritus or pain, but a significant minority of lesions are detected only on examination. Conservative management is often appropriate, but frequently topical corticosteroids and systemic pain medications may be needed. Most vulvar epithelial lesions present with symptoms of pruritus or pain, but a significant minority of lesions are detected only on examination. Conservative management is often appropriate, but frequently topical corticosteroids and systemic pain medications may be needed.

Benign Ovarian Tumors

Mucinous Cystadenoma Serous Cystadenoma Cystic Teratoma Brenner

Additional Illnesses That Are AIDS-Defining in Children but not Adults

Multiple, recurrent bacterial infections (certain types) Lymphoid Interstitial Pneumonia Pulmonary Lymphoid Hyperplasia

OCPs: Side Effects

Nausea, bloating, breast tenderness Breakthrough bleeding Reduces risk of certain cancers Increases risk of cervical cancer Hypertension Venous thromboembolism Pulmonary embolism Stroke No overall weight gain

To give advice on contraceptives a physician needs to understand 2 things:

Need to explain mechanism of action, effectiveness, indications and contraindications, complications Need to know patient and their personal, religious, cultural values

Referred Upper Urinary Pain

Presenting signs and symptoms: colicky flank pain radiating to abdomen, groin or scrotum. Hematuria, gross or microscopic Polyuria, dysuria, emesis, and ileus

Interruption of the Hypothalamic-Pituitary Testicular axis by exogenous steroids

Only low levels of circulating testosterone are required for function of HPT axis For sperm development, intra-testicular levels of testosterone are maintained at a concentration over 100 times greater that in the blood. This is required to maintain spermatogenesis. Administration of exogenous testosterone leads to inhibition of GnRH and pituitary gonadotrophs, specifically decreasing LH production.

Lactational Mastitis

Organism: Staph Aureus Timing: 2nd and 3rd week Postpartum Signs/Symptoms: Firm Redness Myalgias Breast Pain Temp greater than 38.5 degrees Causes Damaged nipples Infrequent feedings Inefficient milk removal Illness in mother or baby Oversupply of milk Rapid Weaning Pressure on Breast Blocked Milk Duct Maternal Stress/excessive fatigue Maternal Malnutrition

changes during the menstrual cycle: Oviduct: Vagina:

Oviduct: increase the muscular and ciliary activity for egg, sperm and zygote transfer Vagina: E stimulates proliferation of epithelium and increases the cells glycogen content P increases desquamation of the epithelial cells. The glycogen is metabolized by lactobacilli, and converted to lactic acid thus maintaining an acidic environment that is hostile to sperm. This also inhibits infection by non-commensal bacteria and fungi

AUB-A (ADENOMYOSIS) Pathogenesis Diagnosis Treatment

Pathogenesis: (Unknown) Theory 1: Endomyometrial invagination of the endometrium Theory II: De Novo from the Mullerian Nests Diagnosis Definitive diagnosis only with microscopic exam s/p hysterectomy MRI and PUS can aid in diagnosis Treatment: Treatment of Choice- Hysterectomy Other possible options have limited benefits: Hormone regulation/suppression Endometrial Ablation UAE

Unintended Consequences of Regional Anesthesia and/or Analgesia

Patients who receive epidural analgesia for labor pain have a similar duration of the first stage of labor, but the second stage may be prolonged by 15 minutes on average. impaired ability to push (unlikely as long as motor block is avoided by appropriate adjustment of the epidural infusion) or to decreased maternal urge to push Other side effects and complications of regional anesthesia or analgesia include fever (0.5° C increase), headache, and backache. The risk of headache is about 1-2% with spinal anesthesia,and it is less than 1% with an epidural. It occurs when there is an unintended dural puncture ("wet tap"). Postdural puncture headaches are self-limited, usually resolving within 5 to 7 days. The hallmark is a severe *positional* headache There appears to be no association between new-onset, long-term back pain and labor epidural analgesia.

Hypergonadotropic Primary Amenorrhea and Sexual Infantilism

Patients with hypergonadotropic hypogonadism have some form of failed gonadal development or premature gonadal failure and have elevated serum FSH levels. These individuals may have gonadal dysgenesis, or an abnormally developed gonad caused by chromosomal defects. In individuals with the presence of a Y chromosome, there is a risk of developing a gonadoblastoma (a benign germ cell tumor of the gonad) and eventually a dysgerminoma (a malignant germ cell tumor). All patients with hypergonadotropic hypogonadism should have a karyotype performed Rarely, some patients have a defect of estrogen and androgen production. One example of this is 17-hydroxylase (P450c17) deficiency, which prevents the synthesis of these sex steroids

Hypothalamic-Pituitary Dysfunction amenorrhea

Patients with hypothalamic amenorrhea include women with severe weight loss, women engaging in excessive exercise resulting in low body fat All patients with hypogonadotropic hypogonadism and hypothalamic-pituitary dysfunction should be evaluated for the status of the other pituitary hormones. When hypothalamic-pituitary dysfunction cannot be resolved by identifying a modifiable underlying cause (e.g., excessive exercise), combination estrogen and progestin therapy, usually in the form of a combined oral contraceptive pill to reduce the risk of osteoporosis.

Primary Amenorrhea with Sexual Infantilism

Patients with primary amenorrhea and no secondary sexual characteristics (sexual infantilism) display an absence of gonadal hormone secretion. The differential diagnosis is based on whether the defect represents a lack of gonadotropin secretion (*hypogonadotropic hypogonadism*) or an inability of the ovaries to respond to gonadotropin secretion (*hypergonadotropic hypogonadism* caused by gonadal agenesis/dysgenesis). The distinction can be made by measuring a basal serum follicle-stimulating hormone (FSH) level. Patients with hypogonadotropic hypogonadism have low serum FSH levels. Whereas patients with hypergonadotropic hypogonadism (e.g., gonadal dysgenesis) have elevated serum FSH levels in the menopausal range (>25 mIU/L)

Müllerian Dysgenesis or Agenesis

Patients with primary amenorrhea, breast development, and a 46,XX karyotype have serum levels of testosterone appropriate for females. This clinical diagnosis may be caused by müllerian defects that cause obstruction of the vaginal canal imperforate hymen a transverse vaginal septum the absence of a normal cervix and/or uterus and normal fallopian tubes

Nephrolithiasis: General Considerations

Peak incidence at age 20-45 y/o Incidence 5x more likely in men More common in developed countries due to increased meat and salt intake, and decreased fiber and water ingestion Hallmarks are intense pain and hematuria (frequently macroscopic) with or without pyuria (UTI or pyelo) 90% pass spontaneously Type of stone must be analyzed, strain urine to catch stone, 24h urine for excretion evaluation Treatment includes pain control, hydration, antibiotics, lithotripsy, ureteroscopy, and surgery Recurrent stone risk increases from 40% in first 2 years to 70% in 10 years (in other words, they're coming back)

Medications That Can Cause or Worsen UI

Pearl: For new onset or worsening incontinence, check if a medication(s) was recently started Oral estrogen is associated with increased risk of urinary incontinence. Not clear why but may be due to effect on collagen metabolism which alters periurethral connective tissue Alcohol α-Adrenergic agonists α-Adrenergic blockers ACE inhibitors Anticholinergics Antipsychotics Calcium channel blockers Cholinesterase inhibitors Estrogen (oral)* GABA agents (gabapentin, pregabalin) Loop diuretics Narcotic analgesics NSAIDs Sedative hypnotics Thiazolidinediones Tricyclic antidepressants

Urinary Fistulas

Pelvic surgery, irradiation, or both now account for 95% of the vesicovaginal fistulas in the United States. More than 50% occur following simple abdominal or vaginal hysterectomy How long after surgery do you think we notice these fistulas? 10-21 days Which type of hysterectomy has the lowest risk of fistulas? How do we diagnose fistulas? Instillation of methylene blue dye into the bladder will discolor a vaginal tampon or pack if a... vesicovaginal fistula is present.

Hernias PE

Perform in both supine and standing positions, with and without the Valsalva maneuver. Identify the sac as well as the fascial defect.

Periodic Fetal Heart Rate Changes: Accelerations Decelerations

Periodic Fetal Heart Rate Changes Periodic FHR changes are changes in baseline FHR related to uterine contractions. The responses to uterine contractions may be categorized as follows: *Accelerations* The FHR increases in response to uterine contractions. This is a normal response and is reassuring that the fetal status is normal. *Decelerations* The FHR decreases in response to uterine contractions

Prolactinomas: Treatment options: Observation

Periodic observation is indicated in normally menstruating women with galactorrhea who have either normal serum prolactin levels or idiopathic elevations of prolactin. As long as the galactorrhea is not socially embarrassing and the patient has regular menses (confirming normal estrogen levels), there is no need to institute treatment. When verified by low serum levels of estradiol (<30 pg/mL) and a negative pregnancy test, cyclic hormone therapy (estrogen and a progestin) should be initiated. Because the growth rate of microadenomas is slow, an annual measurement of serum prolactin is appropriate in patients with normal estrogen levels

Prolactinomas

Pituitary adenomas may cause hyperprolactinemia, and they make up approximately 10% of all intracranial tumors. Their etiology is unknown. Prolactinomas can be divided into two categories: macroadenomas (≥10 mm in diameter) microadenomas (<10 mm in diameter). This distinction is important because microadenomas are unlikely to cause new problems as a result of additional growth.

Chronic Endometritis Causes Tx

Plasma cells on EMB *Possible causes*: infection, foreign body, radiation *Tx* with antibiotics Doxycycline 100mg bid for 10-14 days

Testicular Torsion

Population: 10-20 yr. age group Symptoms: Acute (sudden) onset of pain and swelling of the testis.* -may occur after strenuous activity or minor trauma. -no painful voiding. High incidence in patients with scrotal pain! Testicular torsion occurs when a testicle "torts" on the spermatic cord resulting in the cutting off of a blood supply. *PE*: *Painful testis. Sudden onset. Severe. May have a "high lie" in relation to other testis.* -may be horizontally oriented.* -absent Cremasteric reflex* Most common symptom is acute testicular pain. Most common underlying cause is a bell-clapper deformity. *Diagnosis*: Testicular torsion is a clinical diagnosis! CBC is elevated in 60%. Unreliable as a diagnostic tool Colorflow doppler US-looking at no or decreased blood flow. Radionuclide scan

Postpartum Hemorrhage

Postpartum hemorrhage (PPH), the leading cause of maternal mortality, is defined as blood loss in excess of 500 mL at the time of vaginal delivery or blood loss in excess of 1000 mL following cesarean delivery. Delayed PPH can occasionally occur, with the excessive bleeding commencing more than 24 hours after delivery *Most common causes:* Uterine atony Retained placental tissue Genital tract trauma Low placental implantation Coagulation disorders Inherited coagulopathy Placental abruption (usually ante- or intrapartum)

Gail Model

Predicts the female risk of developing breast cancer over the next 5 years until 90yrs Based on Several Factors: 1, Current Age 2. Age at Menarche 3. Age at First Live Birth 4. Number of first degree relatives with Breast 5. Cancer 5. Number of previous breast biopsy 6. Previous breast bx with atypical hyperplasia 7. Race

Preeclampsia/Eclampsia

Preeclampsia is a multisystem disorder unique to pregnancy and has varying clinical presentations. New-onset hypertension is defined as the development of hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg on two occasions 4 hours apart) in a woman whose blood pressure readings were previously normal, after the 20th week of pregnancy. New-onset proteinuria is defined as ≥0.3 g of protein in a timed 24-hour urine collection or a protein/creatinine ratio ≥0.3 after the 20th week of gestation. preeclampsia is often preceded by, or associated with, the development of generalized edema. A variant of severe preeclampsia with particularly high morbidity is the HELLP syndrome. This syndrome occurs in preeclamptic women with evidence of hemolysis, elevated liver enzymes, and lowplatelets (thrombocytopenia).

Diagnostic work up for PID

Pregnancy test! U/A CBC GC / Chlamydia RPR HIV Pelvic ultrasound --Free fluid in the pelvic cul-de-sac --Rule out tubo-ovarian abscess, ovarian cyst, ovarian torsion

PROM Definition, Incidence, and confirmation tests

Premature rupture of the membranes (PROM) is defined as amniorrhexis (spontaneous rupture of the membranes as opposed to amniotomy) before the onset of labor at any stage of gestation. Diagnosis of PROM is based on the history of vaginal loss of fluid and confirmation of amniotic fluid in the vagina Because of the risk of introducing infection and the usually long latency period from the time of examination until delivery, the examiner's hands should not be inserted into the vagina of a patient who is not in labor, whether preterm or term. *Confirmation* of the diagnosis can be made by: nitrazine paper test: amniotic fluid will turn blue with alkaline amniotic fluid, fern test: placing a sample of amniotic fluid on a slide left to air dry will show ferning AmniSure test: a highly accurate test measuring placental alpha microglobulin-1 (PAMG-1), which is present in high levels in amniotic fluid.

Uterine cycle:secretory phase

Preparation for implantation Under influence of P and E Coincides with luteal phase P induces differentiation of epithelial and stromal cells. P induces uterine glands to fill with glycogen vacuoles to support embryo. P inhibits endometrial growth. It opposes the proliferative actions of E by down-regulating the ER. P induces inactivating isoforms of 17b-HSD so that active estradiol is converted to the inactive estrone. This is important for protecting the endometrium from estrogen induced uterine cancer.

Acute Bacterial Prostatitis

Present with fever, chills, dysuria, and perineal or low back pain/sepsis PE reveals warm, tender prostate with induration. Also can show bladder distention (overaggressive manipulation of the prostate can cause sepsis) Lab shows elevated WBC with pos UA, culture and sensitivity Tx includes hospitalization if acutely ill, IV abx with G- coverage

Chronic Bacterial Prostatitis

Presents with pain (perineal, LBP, groin or scrotal), dysuria, frequency, urgency, nocturia, and weak stream ?ejaculodynia? PE shows normal or enlarged prostate with variable palpatory pain UA is done 3 step: first void urine (VB-1), midstream urine (VB-2) followed by prostate massage and collection of EPS, then post massage urine (VB-3) Dx = 10x WBC (or colonies) in EPS or VB-3. Tx includes gram - coverage for 6 weeks

Urinary incontinence is present in: What's the impact?

Prevalence Urinary incontinence is present in: 15%-30% of community-dwelling adults ≥ 65 years 60%-70% of residents of long-term-care institutions What's the impact? It impairs quality of life General health Social function (social withdrawal) Emotional well-being Risk for long term care placement Note: Urinary incontinence is NOT associated with mortality

Priapism

Priapism is a persistent, usually painful, erection that lasts for more than four hours and occurs *without* sexual stimulation.* The condition develops when blood in the penis becomes trapped and unable to drain. * If the condition is not treated immediately, it can lead to scarring and permanent erectile dysfunction* Usually affects men between the ages of 5 to 10 years and 20 to 50 years.*

HIV Sex-Specific Manifestations

Primarily focused on women, and are responsive to therapy. Consider testing. Earliest clinical manifestation in female may be recurrent Candida vaginitis (CD4 often >200). Recurrent large, painful genital/perianal or perineal ulcerations from HSV-2 (more common women) Risk of cervical dysplasia and neoplasia (HPV) HIV+ need pap smears every 6 months

GnRH (Gonadotropin releasing hormone)

Produced in arcuate nucleus and preoptic area of hypothalamus GnRH is a decapeptide that is synthesized as a preprohormone (92AA) cleaved to a prohormone (69AA) and then cleaved to make the decapeptide. The 56AA peptide that is left is called GnRH associated hormone (GAP) The neuron secretes both GnRH and GAP into portal circulation, but the role of GAP is unknown (it may inhibit prolactin secretion)

GRANULOSA CELL TUMOR

Produces granulosa cells which normally are found in the ovary It is malignant in 20% of women with diagnosis It tends to present in women in the 50-55yo age group with post menopausal vaginal bleeding

Management of Vaginal prolapse Non surgical

Prophylactic measures to mitigate the symptoms of POP include identifying and treating chronic respiratory and metabolic disorders, correction of constipation and intraabdominal disorders that may cause repetitive increases in intraabdominal pressure, and, for menopausal women, administration of estrogen. *Nonsurgical Treatment* When only a mild degree of pelvic relaxation is present, pelvic floor muscle exercises may improve the tone of the pelvic floor musculature. Pessaries (Figure 23-4), which provide intravaginal support, may be used to correct prolapse by internally supporting the vagina. They can be considered when the patient is medically unfit or refuses surgery Pessaries require proper fitting and must be selected in the appropriate type and size. They should be removed, cleaned, and reinserted every 6 to 12 weeks. They may cause vaginal irritation and ulceration *Surgical Treatment* The main objectives of surgery are to relieve symptoms and restore normal anatomic relationships and visceral function. Repair of Vaginal Prolapse Anterior colporrhaphy corrects anterior vaginal wall prolapse and helps support the urethra. It involves plication of the pubocervical fascia to support the bladder and urethra. Posterior colporrhaphy corrects a posterior vaginal wall prolapse and is similar in principle to anterior colporrhaphy. Perineorrhaphy repairs a deficient perineal body.

2010 CDC STD Treatment Guidelines: Gonorrhea

Recommended Ceftriaxone (cephalosporin 3rd gen) 250 mg IM x 1 PLUS Azithromycin (macrolide) 1gm PO x 1 Or Doxycycline (tetracycline) 100mg PO BID x 7d

Prolactinomas: Treatment options: Surgery

Recurrence rates for microadenomas after surgery approach 30%, and the rate increases to 90% for macroadenomas. For this reason, medical management is preferred Patients with amenorrhea or oligomenorrhea who consistently have normal levels of estrogen have a mild form of hypothalamic anovulation that may be caused by low body weight and exercise issues, psychological stress, recent pregnancy, or lactation. Some women with amenorrhea and/or oligomenorrhea and normal estrogen levels may have a subclinical androgen excess disorder, such as a mild form of polycystic ovarian syndrome (PCOS). When contraception is not required in these anovulatory women and fertility is not desired, periodic progestin withdrawal to confirm normal estrogen levels and protect the endometrium is appropriate. When fertility is not desired, combination hormonal contraception is appropriate.

Genitourinary disorders associated with HIV

Recurrent HSV Primary Syphilis (chancre) Vulvovaginits --Most often Candida Bacterial vaginosis and Trichomoniasis Human Papilloma Virus --Risk of Cervical cancer --Anal carcinoma (especially homosexual males)

Relaxin

Relaxes pubis Helps dilate cervix

The Abnormal Pap: Follow up (ASCUS)

Repeat Cytology in 6 months If its: *Normal*-Repeat Cytology in one Year *ASC*-Colposcopy (HPV +)

Placenta Accreta, Increta, Percreta

Represents the abnormal attachment of the placenta to the uterine lining due to an absence of the decidua basalis and an incomplete development of the fibrinoid layer Variations of abnormal attachment: placenta accreta, placenta increta and placenta percreta Will likely need to have manual uterine exploration minimum. Hysterectomy likely. A is Against or Accreta, I is Increata or I the wall (myometrium) of uterus, P is Per or through for percreta

anti-D immune globulin

Rhogam WinRho SDF: has Maltose MicRhoGam Rhophylac HyperRHO S/D Full Dose HyperRHO S/D mini-Dose Future Recombinant polyclonal human anti-D Routine cffDNA testing Marry well Gel microcolumn assay (GMA) card (indirect Coombs replacement) for mat'l titers

Molar Pregnancy

Risk Factors Extremes in maternal age History of previous mole Lower socio-economic status Essentials of Diagnosis 1st trimester uterine bldg Rapid increase of uterine size >dates B-hCG titers >gestational age Vaginal expulsion of vesicles Preeclampsia before 24 weeks

RH Tests

Rosette test Kleihauer-Betke Flow cytometry Maternal fetal hemoglobin Cell-free fetal DNA (cffDNA) Fetal RHD gene determination Rh factor blood typing mom and dad Titer anti-D immune globulin Paternity history "certainty" Anti-C and anti-G Ask for Blood Bank consult Paternal Zygosity:Rh D, C/c, E/e, G Single neucleotide polymorphisms (SNPs) Amniocytes at 15 weeks by PCR (fetal Rh(D))

Tomosynthesis (3D Mammography)

Rotational mammography Moving xray and a digital detector Analogous to a CT scan Only 40 degrees of rotation Small number of discrete exposures/ images FDA approved in 2011 as an adjunct to standard mammography Decreases recall and biopsy by identifying true lesions from false lesions caused by overlapping structures seen on mammogram.

Four paired sets of ligaments are attached to the uterus

Round ligaments Uterosacral ligaments Cardinal ligaments Pubocervical ligaments Vesicouterine fold Rectouterine fold Two broad ligaments—the fold of the broad ligament containing the fallopian tube is called the mesosalpinx

Mammography

Same concept as an Xray Lower energy beam (25kV) Ideal for identifying small, high density material such as calcifications (mass 1mm to 1cm in size) Increased scatter in women with dense breasts False Negative Rate is 10-20% Five or More Clustered calcifications or space occupying lesions in two different projections are suggestive of cancer. Potential to dectect a mass 3 yrs prior to its being palpable (2cm)

Chronic Nonbacterial Prostatitis/CPPS (inflammatory)

Same sx's as CBP, but no causative agent identified PE: prostate may be normal UA normal, the EPS may have WBC's but no growth on C & S Tx with warm baths, prostatic massage for infrequent ejaculators, and NSAIDS. Abx are controversial, but used

Septal Wall Thickening

Septa in a cystic ovarian mass are strong evidence of a neoplasm more likely to indicate malignancy if they are greater than 2-3 mm in thickness or have detectable flow on Doppler US scans A cystic ovarian mass with septa (particularly when thin) but without a solid component is likely to be a benign neoplasm, though occasionally may be malignant when there are a very large number of septa

Delivery of Placenta

Signs of placental separation are as follows: a fresh show of blood from the vagina the umbilical cord lengthensoutside the vagina, the fundus rises up the uterus becomes firm and globular Finally, the placenta should be examined to ensure its complete removal (no missing cotyledons) and to detect placental abnormalities.

Appendiceal Torsion

Similar age population as Testicular torsion More than 80% of cases occurring in children aged 7-14 year The leading cause of "acute scrotum" in children Symptoms are similar to Testicular Torsion Necrotic tissue is reabsorbed without any sequelae in almost all cases History is important Pain ranges from mild to severe. Pain, although acute, may develop gradually over time. Patients may endure pain for several days before seeking medical attention.* Pain is located in the superior pole of the testicle.* Torsion of the testicular appendices is virtually a benign condition, but, must be distinguished from testicular torsion! *PE* The testes should not be tender (except in the superior pole).* An unreliable marker of pathology, the cremasteric reflex is usually intact.* May feel a small palpable lump on the superior pole of the testis. -Site may appear blue when the skin is pulled tautly over the area ("blue dot sign"). The Blue-dot sign combined with non-tender testes excludes testicular torsion.* a reactive hydrocele is usually present that may transilluminate, and tenderness can often be localized to the exact location of the appendix testis on the anterosuperior testis the classic "blue dot" sign (picture 2), caused by infarction and necrosis of the appendix testis

Endometrial Hyperplasia -WHO Classification

Simple Hyperplasia without Atypia Complex Hyperplasia without Atypia Simple Atypical Hyperplasia Complex Atypical Hyperplasia Without Nuclear Atypia: D & C can be therapeutic Progestin treatment With Nuclear Atypia: Potential for progression to adenocarcinoma Hysterectomy If Dx by EMB, do D&C to r/o adenocarcinoma

Layers of the abdominal wall

Skin Subcutaneous fat Superficial fascia (Camper) Deep fascia (Scarpa) The anterior rectus sheath and abdominal muscles Peritoneum

Characteristics of Malignant Adenexal Mass

Solid Multiple septations >2-3 mm Cystic & Solid Bilateral Ascites Nodular Fixed Solid

ULTRASOUND features suggestive of malignancy:

Solid component Doppler flow (Hypervascularity) Thick septations (wall thickening) Size Presence of ascites or other peritoneal masses

atrophic vaginitis

Some dermatologic changes may occur due to the effect of lower estrogen levels on the vaginal epithelium during pregnancy or after the menopause. The resulting atrophic vaginitis may be treated with estrogen cream. Infectious lesions such as vaginal warts from HPV or herpes simplex blisters can affect the vaginal epithelium.

Stages of Ovarian Cancer

Stage I: Growth limited to the ovaries. Stage IA: Growth limited to one ovary; no ascites. No tumor on the external surface; capsule intact. Stage IB: Growth limited to both ovaries; no ascites. No tumor on the external surfaces; capsules intact. Stage IC: Tumor either stage IA or IB but with tumor on the surface of one or both ovaries; or with capsule ruptured; or with ascites present containing malignant cells or with positive peritoneal washings. Stage II: Growth involving one or both ovaries with pelvic extension. Stage IIA: Extension and/or metastases to the uterus and/or tubes. Stage IIB: Extension to other pelvic tissues. Stage IIC: Tumor either stage IIA or IIB but with tumor on the surface of one or both ovaries; or with capsule(s) ruptured; or with ascites present containing malignant cells or with positive peritoneal washings. Stage III: Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes. Superficial liver metastasis equals stage III. Tumor is limited to the true pelvis but with histologically verified malignant extensions to small bowel or omentum. Stage IIIA: Tumor grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces. Stage IIIB: Tumor of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter. Nodes negative. Stage IIIC: Abdominal implants more than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes. Stage IV: Growth involving one or both ovaries with distant metastasis. If pleural effusion is present, there must be positive cytologic test results to allot a case to stage IV. Parenchymal liver metastasis equals stage IV.

Vaginal Dryness and Genital Atrophy

Structures that are estrogen-dependent Vaginal epithelium Cervix Endocervix Endometrium Myometrium Uroepithelium With decreasing estrogen, these tissues become atrophic with various secondary symptoms Vaginal epithelium thins Cervical secretions diminish causing vaginal dryness and possible dyspareunia. Atrophic vaginitis May present with itching and burning Atrophic changes to the endometrium can cause postmenopausal spotting

Atypical Hyperplasia (ADH and ALH)

Substantial increased risk for Breast Cancer Increased risk of both ipsilateral and contralateral Breast Cancer Similar Features of DCIS and LCIS Stop OCP and HRT Yearly Mammogram and Twice yearly CBE Possible prophylactic treatment with tamoxifen/raloxifen or Aromatase Inhibitor Diagnose with Core Biopsy followed by Wire Localization Breast Biopsy.

Hormonal regulation of lactation

Sucking is required to stimulates the release of prolactin and maintain ongoing lactogenesis. High levels may inhibit GnRH resulting in "natural" birth control Oxytocin required for milk-let down. This causes contraction of the myoepithelial cells

Stages of Labor (4)

The *first* stage lasts from the onset of true labor to complete dilation of the cervix. The *second* stage spans from complete dilation of the cervix to the birth of the baby. The *third* stage lasts from the birth of the baby to delivery of the placenta. The *fourth* stage spans from delivery of the placenta to stabilization of the patient's condition, usually at about 6 hours postpartum.

Apgar Score

The Apgar score is an excellent tool for assessing the overall status of the newborn soon after birth (1 minute) and after a 5-minute period of observation. A normal Apgar score is 7 or greater at 1 minute and 9 or 10 at 5 minutes. *HR* 0=absent, 1= <100bpm, 2= >100bpm *Resp effort* 0=absent, 1=slow weak cry, 2= good, strong cry *Muscle tone* 0= Limp, 1= some flexion of extremities, 2= active motion *Reflex irritability (sole of foot)* 0=none, 1= Grimace, 2= Strong cry *Color* 0= Pale/blue, 1= pink body, blue extremities, 2= complexly pink

Rhesus Alloimmunization

The Rh complex is made up of a number of antigens (C, D, E, c, d, e and other variants) More than 90% of cases of Rh alloimmunization are due to antibodies to the D antigen, and this is the only form of alloimmunization that can be prevented with Rh immune globulin prophylaxis. A person who lacks the D antigen on the surface of the red blood cells is regarded as being "RhD-negative" and an individual with the D antigen is considered to be "RhD-positive." Most immunizations occur at the time of delivery. In general, two exposures to RhD antigen are required to produce any significant sensitization. The first exposure leads to primary sensitization, the second causes a response leading to rapid production of immunoglobulins. If the hemolysis is severe, it can lead to profound anemia and ultimately heart failure (hydrops fetalis) and IUFD. If a woman has a history of fetal hydrops with a previous pregnancy, the risk of hydrops with a subsequent pregnancy is about 90%. All pregnant RhD(-) women who are not sensitized to the D antigen should routinely receive prophylactic Rh immune globulin at 28 weeks gestation, within 72 hours of delivery of an RhD(+) fetus and at the time of recognition of any instances of feto-maternal hemorrhage. The Kleihauer-Beke test is dependent on the fact that adult hemoglobin is more readily eluted throughout the cell membrane in the presence of acid than is fetal hemoglobin. With testing, fetal and maternal cells are easily distinguished and fetal cells are counted. The percentage of fetal cells present is used to estimate the extent of feto-maternal hemorrhage.

Importance of Transvaginal Ultrasound for evaluating masses

The Transvaginal sonographic approach yields the greatest amount of information during real-time scanning In asymptomatic women with pelvic masses, whether premenopausal or postmenopausal, Transvaginal ultrasonography is the imaging modality of choice No alternative imaging modality has demonstrated sufficient superiority to Transvaginal ultrasonography to justify its routine use

The android pelvis

The android pelvis is the typical male type of pelvis. It is found in less than 30% of women and has the following characteristics: Triangular inlet with a flat posterior segment and the widest transverse diameter closer to the sacrum than in the gynecoid type Convergent sidewalls with prominent spines Shallow sacral curve Narrow subpubic arch This type of pelvis has limited space at the inlet and progressively less space as the fetus moves down the pelvis, because of the funneling effect The fetal head is forced to be in the occipitoposterior position to conform to the narrow anterior pelvis. Arrest of descent is common at the midpelvis.

You are consulted by the ED at 0300 on a Friday evening for pelvic pain. The patient is a 20 year-old G0 with a negative HCG. She is afebrile, and she has a benign exam. Ultrasound shows a left-sided simple 3 cm ovarian cyst with no free fluid in the pelvis. Your next step is to: A. Ask the ED resident if a pelvic exam was done B. Tell the patient this is likely the source of her pelvic pain and she will need surgery C. Recommend follow up in the PCC in 4-6 weeks with a repeat U/S

The answer is C 70% of simple cysts in premenopausal females will resolve spontaneously, and the current recommendation is to follow these every three months by ultrasonography until resolution. Should the lesion increase in size or develop complex features, surgery would be warranted

Pituitary Gland

The anterior pituitary contains different cell types that produce six protein hormones: Follicle-stimulating hormone (FSH) Luteinizing hormone (LH) Thyroid-stimulating hormone (TSH) Prolactin Growth hormone (GH) Adrenocorticotropic hormone (ACTH) The gonadotropins, FSH and LH, are synthesized and stored in cells called gonadotrophs. FSH, LH, and TSH consist of α and β subunits. The α subunits of FSH, LH, and TSH are identical. The same α subunit is also present in human chorionic gonadotropin (hCG). The β subunits are individual for each hormone.

Anterior Vaginal Prolapse (Cystocele)

The anterior vagina is the most common site of vaginal prolapse.Women with this type of defect will describe symptoms of vaginal fullness, heaviness, pressure, and/or discomfort that often progress over the course of the day and are most noticeable after prolonged standing or straining. Significant anterior vaginal wall prolapse that protrudes beyond the vaginal opening (hymen) can cause urethral obstruction caused by kinking, resulting in urinary retention or incomplete bladder emptying.

Epithelial Changes of the Vulva

The appearance of the vaginal walls varies greatly from one woman to another. In part, this is because the epithelium is very sensitive to estrogen. In well-estrogenized women, the epithelium is pink, moist, thickened, and folded into distensible rugae. The epithelium of the vagina is also subject to chemical irritants and contact dermatitis with the use of various solutions for douching, allergic reactions to vaginal antibiotic or antimycotic creams, spermicides, or latex contraceptives.

Fetal Heart Rate Patterns

The assessment of the FHR depends on an evaluation of the baseline pattern and the periodic changes related to uterine contractions. Baseline assessment of FHR requires the determination of the rate (in beats/min) and the variability. Normal FHR baseline is from 110 to 160 beats/min *Tachycardia* is a baseline greater than 160 beats/min *Bradycardia* is less than 110 beats/min. Baseline variability can be divided into short- and long-term intervals

Postterm Pregnancy

The prolonged or postterm pregnancy is one that persists beyond 42 weeks (294 days) from the onset of the last normal menstrual period. Estimates of the incidence of postterm pregnancy range from 6-12% of all pregnancies. Perinatal mortality is two to three times higher in these prolonged gestations. fetal postmaturity (dysmaturity) syndrome, which occurs when a growth restricted fetus remains in utero beyond term. Occurring in 20-30% of postterm pregnancies, this syndrome is related to the aging and infarction of the placenta, with resulting placental insufficiency.

Bimanual Examination

The bimanual pelvic examination provides information about the uterus and adnexa The labia are separated, and the gloved, lubricated index finger is inserted into the vagina. The cervix is palpated for consistency, contour, size, and tenderness to motion. The uterus is evaluated by placing the abdominal hand flat on the abdomen with the fingers pressing gently just above the symphysis pubis. With the vaginal fingers supinated in either the anterior or the posterior vaginal fornix, the uterine corpus is pressed gently against the abdominal hand As the uterus is felt between the examining fingers of both hands, the size, configuration, consistency, and mobility of the organ are appreciated. If the muscles of the abdominal wall are not compliant or if the uterus is retroverted, in these circumstances, however, it is impossible to discern uterine size accurately. It is usually impossible to feel a normal tube Conditions must be optimal to appreciate the normal ovary

Continence Control female

The bladder must store and hold urine painlessly and then, in the appropriate social setting, empty urine effectively. The normal bladder holds urine because the intraurethral pressure exceeds the intravesical pressure. The pubourethral ligaments and surrounding endopelvic fascia support the urethra so that abrupt increases in intraabdominal pressure are transmitted equally to the bladder and proximal third of the urethra, thus maintaining a pressure gradient between the two structures. Stress urinary incontinence (SUI) is involuntary leakage of urine in response to physical exertion, sneezing, or coughing.

Velamentous Placenta(Vasa Previa )

The blood vessels are not contained within the umbilical cord (where they normally are) and instead are found in the membranes leading off of the placenta

Bony Pelvis

The bony pelvis is made up of the two paired innominate bones and the sacrum. The symphysis pubis is formed anteriorly at the attachment of both innominate bones. The sacrum has five to six vertebrae that are fused in the adult. The sacrum articulates posteriorly with each innominate bone at the sacroiliac joints.

Nuchal Cord

The cord may become coiled around various parts of the body of the fetus, usually around the neck. Nuchal cord is caused by movement of the fetus through a loop of cord. One loop around the neck occurs in approximately 20% of cases, and multiple loops occur in up to 5% of pregnancies. Nuchal cord has been associated with labor induction and augmentation, prolonged second stage of labor, and fetal heart rate abnormalities. One report has described a decrease in umbilical cord pH at delivery with nuchal cord, but the difference found (7.32 vs 7.30) does not appear to be clinically significant.Nuchal cord can be detected using color Doppler ultrasound, with a sensitivity of over 90%.

PTB Diagnosis & Management

The diagnosis of preterm labor between 20 and 37 weeks is based on the following criteria in patients with ruptured or intact membranes: documented uterine contractions (4 per 20 minutes or 8 per 60 minutes) documented cervical change (cervical effacement of 80% or cervical dilation of 2 cm or more) Uterine contractions are not a good predictor of preterm labor, but cervical changes are. With adequate hydration and bed rest, uterine contractions cease in approximately 20% of patients. Cultures should be taken for group B Streptococcus. Antibiotics should be administered to patients who are in preterm labor An ultrasonic examination of the fetus should be performed to assess: fetal weight, document presentation assess cervical length rule out the presence of any accompanying congenital malformation. If the patient does not respond to bed rest and hydration, tocolytic therapy should be instituted, provided that there are no contraindications

Primary Amenorrhea

The diagnosis of primary amenorrhea is made when no spontaneous uterine bleeding has occurred by the age of 16 years. The workup should be initiated earlier if there is no evidence of breast development (thelarche) by age 14 years or if the patient has not menstruated (menarche) spontaneously within 2 years of thelarche.

Amenorrhea or Oligomenorrhea Associated with Hypoestrogenism

The differential diagnosis for patients with amenorrhea associated with low serum levels of estrogen includes hypothalamic and/or pituitary dysfunction (hypothalamic amenorrhea) premature ovarian failure hyperprolactinemia

Evaluation of Acute Scrotal Pain in Adult Men

The differential diagnosis must include: Testicular Torsion Epididymitis Fournier's gangrene Hernias -Do a detailed examination of the abdomen, testes, epididymis, cord, scrotal skin, and inguinal region.

Implantation

The fertilized ovum reaches the endometrial cavity about 3 days after ovulation. Hormones influence egg transportation. Estrogen causes "locking" of the egg in the tube, and progesterone reverses this action. Initial embryonic development primarily occurs in the ampullary portion of the fallopian tube with subsequent rapid transit through the isthmus. On reaching the uterine cavity, the embryo undergoes further development for 2 to 3 days before implanting. The decidua basalis enters into the formation of the basal plate of the placenta. The Nitabuch layer is a zone of fibrinoid degeneration where the trophoblast meets the decidua. When the decidua is defective, as in placenta accreta, the Nitabuch layer is absent.

Maneuvers of Leopold

The first maneuver involves palpating the fundus to determine which part of the fetus occupies the fundus. The second maneuver involves palpating either side of the abdomen to determine on which side the fetal back lies. The third maneuver involves grasping the presenting part between the thumb and third finger just above the pubic symphysis to determine the presenting part. The fourth maneuver involves palpating for the brow and the occiput of the fetus to determine fetal head position when the fetus is in a vertex presentation.

Threatened Abortion

The term threatened abortion is used when a pregnancy is complicated by vaginal bleeding before the 20th week. 25-50% of threatened abortions eventually result in loss of the pregnancy.

Strategies for Fetal Resuscitation

The three simple interventions are to change the woman's position to the left lateral recumbent, or if she is already on her side, switch positions to the other side reduce the infusion rate of oxytocin if this is running increase intravenous fluids by infusing 1 L of normal saline with either 5% or 10% dextrose to ensure adequate vascular volume and substrate for the fetus and placenta.

Circumvallate Placenta

The top placenta shows a partial ring of thickened tissue from the membranes along the edge of the placenta The bottom picture (above) shows a complete ring of tissue along the edge

The First Prenatal Visit

The first prenatal visit provides an opportunity to review medical, reproductive, family, genetic, nutritional, and psychosocial histories. Reproductive histories that include preterm birth, low birth weight, preeclampsia, stillbirth, congenital anomalies, and gestational diabetes are important to record because of the substantial risk of recurrence. Women with prior cesarean delivery should be asked about the circumstances of the delivery, and discussion about options for the mode of delivery for the current pregnancy should be initiated. Additionally, the importance of screening women for domestic violence cannot be overemphasized. A complete physical examination should be performed including assessment of the patient's body mass index (BMI). During the breast examination, clinicians should initiate discussion about breastfeeding. What are the benefits? A pelvic examination should be performed The appearance and length of the cervix Status of the last Papanicolaou (Pap) smear should be documented, or a new Pap smear obtained. UA & Culture: UTI , bacteria, diabetes mellitus, preeclampsia CBC: anemia, infections

Medical & Surgical Management of Chronic Pelvic Pain

The gynecologist continues to assess progress, coordinate care, and provide periodic gynecologic examinations. In the initial stages of therapy, a trial of ovulation and or menstrual suppression with combined hormonal contraception (pills, patches, rings; cyclic or continuous), high-dose or intrauterine progestins or a gonadotropin-releasing hormone analogue (GnRH-a) may be helpful. Surgical procedures that have not proved to be effective for CPP without pathology include unilateral adnexectomy for unilateral pain total abdominal hysterectomy, presacral neurectomy, or uterine suspension for generalized pelvic pain Without proof of organic pathology or a reasonable functional explanation for the pelvic pain, a thorough psychosomatic evaluation should be carried out before any surgical procedure is considered.

Fourth Stage of Labor

The hour immediately following delivery and the first 4 hours postpartum require continued close observation of the patient The *puerperium* consists of the period following delivery of the baby and placenta to approximately 6 weeks postpartum

Preterm Birth: Risk Factors

The important risk factors for PTB are: history of previous PTB a family history of PTB smoking (including second hand) a history of recurrent early pregnancy losses previous cervical surgery Obesity substance abuse medical conditions such as hypertension and diabetes.

Operative Delivery

The incidence of operative obstetric delivery in the United States today is approximately 35-40%, of which 10-15% are operative vaginal deliveries using either a forceps or a vacuum device. Approximately 25-30% of all deliveries are cesarean deliveries. To shorten the second stage of labor for maternal benefit. Maternal conditions such as hypertension, cardiac disorders, or pulmonary disease, in which strenuous pushing in the second stage of labor is considered hazardous, may be indications for forceps delivery. Epidural analgesia, which also decreases strenuous pushing during the second stage of labor, may also be recommended for this purpose. Before performing a forceps-assisted vaginal delivery, appropriate consent from the patient regarding potential risks and benefits should be obtained.

Placenta Previa

The incidence of placenta previa, the most common type of abnormal placentation, is 0.5%. Approximately 20% of all cases of antepartum hemorrhage are due to placenta previa *Predisposing Factors* Factors that have been associated with a higher incidence of placenta previa include (1) multiparity, increased maternal age; (3) prior placenta previa; (4) multiple gestation; and (5) cesarean delivery Patients with a prior placenta previa have a 4-8% risk of having placenta previa in a subsequent pregnancy. Complete placenta previa implies that the placenta totally covers the cervical os Partial placenta previa implies that the placenta partially covers the internal cervical os. A marginal placenta previa is one in which the edge of the placenta extends to the margin of the internal cervical os.

Internal Fetal Monitoring Contractions and Fetal blood flow

The internal uterine catheter allows precise measurement of the intensity of the contractions in millimeters of mercury Blood flow from the maternal circulation, which supplies the fetus with oxygen through placental exchange of respiratory gases, is momentarily interrupted during a contraction. A normal fetus can withstand the temporary reduction in blood flow to the placenta without developing hypoxia because sufficient oxygen exchange occurs during the interval between contractions.

Laparoscopic Hysterectomy

The laparoscope is used by some surgeons to replace an abdominal procedure (laparoscopic hysterectomy), to assist in a vaginal hysterectomy, and to convert an abdominal hysterectomy to a vaginal hysterectomy. Adoption of laparoscopy-associated hysterectomy has been increasing in recent years.

Innervation of the urinary tract

The lower urinary tract is under the control of both parasympathetic and sympathetic nerves. The parasympathetic fibers originate in the sacral spinal cord segments S2 through S4.Stimulation of the pelvic parasympathetic nerves and The sympathetic fibers originate from thoracolumbar segments (T10-L2) of the spinal cord. *Sensory Innervation* Afferent impulses from the bladder, trigone, and proximal urethra pass to the S2 through S4 levels of the spinal cord by means of the pelvic hypogastric nerves. The sensitivity of these nerve endings may be enhanced by acute infection, interstitial cystitis, radiation cystitis, and increased intravesical pressure.

Lymphatic Drainage of the female peritoneum

The lymphatic drainage of the vulva and lower vagina is principally to the inguinofemoral lymph nodes The lymphatic drainage of the cervix takes place to the pelvic nodes and then to the common iliac and para-aortic chains The lymphatic drainage from the endometrium is to the pelvic and para-aortic chains. The lymphatics of the ovaries pass to the pelvic and para-aortic nodes

Overactive Bladder/Urge Urinary Incontinence

The terms overactive bladder (OAB) and urge urinary incontinence (UUI) are often used interchangeably to describe a problem with bladder control that is associated with a strong desire to pass urine with a decreased ability to control it. Treatment The optimal treatment of OAB starts with behavior modification Reducing fluid intake Avoiding liquids during the evening hours Kegel exercises Pharmacologic and physical interventions Antimuscarinics Anticholinergics Electrical stimulation: stimulation of the afferent fibers of the pudendal nerve produce contractions of the pelvic floor, improving their tone and function Identification of any dietary triggers, such as caffeine, alcohol, acidic or spicy foods, or carbonated beverages, is important. The use of a self-report bladder diary can be helpful for obtaining this information.

Management of Vaginal prolapse Surgical

The main objectives of surgery are to relieve symptoms and restore normal anatomic relationships and visceral function. *Repair of Vaginal Prolapse* Anterior colporrhaphy corrects anterior vaginal wall prolapse and helps support the urethra. It involves plication of the pubocervical fascia to support the bladder and urethra. Posterior colporrhaphy corrects a posterior vaginal wall prolapse and is similar in principle to anterior colporrhaphy. Perineorrhaphy repairs a deficient perineal body. *Repair of Apical Prolapse* When the uterus is present, hysterectomy may be performed to facilitate exposure of the apical support structures. Hysterectomy, however, is not an absolute requirement in settings where uterine removal is not otherwise indicated or desired The uterosacral ligaments can be reattached to the cervix by either the vaginal or abdominal route. Vaginal vault suspension (colpopexy) for apical prolapse is performed to secure a durable fixation point for the top of the vagina. This can be accomplished vaginally or abdominally *Vaginal Closure Procedures* For women with advanced vaginal prolapse who no longer desire coital function, there are less invasive surgical options. A LeFort colpocleisis involves suturing the partially denuded anterior and posterior vaginal walls together in such a way that the uterus remains in situ and is supported above the partially occluded vagina. In women with posthysterectomy prolapse, a complete colpocleisis involves total obliteration of the vagina.

Decision to Incision (C-section)

The major issue is to determine the optimal time for intervention, either by vaginal or cesarean delivery, to avoid serious perinatal morbidity and mortality. There are published data to suggest that, in the presence of Category III FHR patterns, the optimal time for delivery is within 30 minutes; thus, the delivery team must act quickly to decide whether there is sufficient time for a vaginal delivery, keeping in mind that it takes at least 30 minutes to prepare for an emergency cesarean delivery.

Uterine Atony

The majority of PPH cases (75-80%) are due to uterine atony Risk Factors History of postpartum hemorrhage* Prolonged labor* Grand multiparity (a parity of 5 or more) Overdistention of the uterus --Multiple gestations --Polyhydramnios --Fetal macrosomia Chorioamnionitis Uterine leiomyomata Failure of the uterus to contract after placental separation (uterine atony) leads to excessive placental site bleeding.

Secondary Dysmenorrhea

The mechanism of pain in secondary dysmenorrhea depends on the underlying (secondary) cause and in most cases is not well understood. Endometriosis Pelvic Inflammation Adenomyosis Leiomyoma Ovarian cysts *Treatment* Management consists of the treatment of the underlying disease

Fontanelles

The membrane-filled spaces located at the point where the sutures intersect are known as fontanelles, the most important of which are the anterior and posterior fontanelles. Clinically, they are even more useful than the sutures for determining the fetal head position. The posterior fontanelle closes at 6 to 8 weeks of life The anterior fontanelle does not become ossified until approximately 18 months.

Hypothalamic-pituitary-ovarian axis control of menstrual cycle

The menstrual cycle is typically 28 days but can be highly variable during adolescence and the pre-menopausal period. The menstrual cycle involves two organs Ovary: follicular and luteal phases separated by ovulation Uterus (endometrial cycle): menstrual, proliferative and secretory phases The monthly pattern results from the interaction of ovarian steroids and peptides and their ability to exert both positive and negative feedback on the hypothalamus and pituitary 14 day ovulation results in a change to luteal phase from follicular phase in the ovarian cycle and to secretory phase from proliferative phase in the endometrial cycle.

Ovaries

The mobility of the fimbriated end of the tube plays an important role in fertility. The ampullary portion of the tube is the most common site of ectopic pregnancies. The blood supply to the ovaries is provided by the long ovarian arteries, which arise from the abdominal aorta immediately below the renal arteries. The venous drainage from the right ovary is directly into the inferior vena cava, whereas that from the left ovary is into the left renal vein

Antepartum Hemorrhage: Etiology

The most common causes of maternal death are hemorrhage, embolism, hypertensive disease, and infection. The antepartum causes include placenta previa and accreta, conditions that represent abnormalities of placentation. Placental abruption and fetal causes of bleeding may also present before labor and may result in fetal death. Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide, and its prevention is an important part of labor management. Uterine atony, genital tract birth trauma, and placental retention are the most common causes of PPH. Incidence of bleeding in the late second trimester and the third trimester is between 5% and 8%, Critical for the well-being of both the mother and the fetus that the patient who presents with bleeding in the late second trimester and the third trimester be evaluated and managed emergently.

Stress urinary incontinence (SUI) Etiology

The most commonly accepted theory for the pathogenesis of SUI is urethral hypermobility due to vaginal wall relaxation that displaces the bladder neck and proximal urethra downward. The second possible mechanism is intrinsic sphincter deficiency whereby the urethra fails to close in response to increases in intraabdominal pressure. This cause of SUI is analogous to having a leaky "valve" in the urethra. Factors that contribute to SUI include childbearing, previous urogenital surgery or trauma, pelvic radiation, estrogen deficiency (menopause), and medications, such as diuretics and α-adrenergic blockers.

Abdominal Incisions

The most commonly used lower abdominal incision in gynecologic surgery is the *Pfannenstiel* incision. It gives limited exposure for extensive operations, it has cosmetic advantages in that it is generally only 2 cm above the symphysis pubis. Because the rectus abdominis muscles are not cut, eviscerations and wound hernias are extremely uncommon. For extensive pelvic procedures, a transverse muscle-cutting incision (*Maylard*) at a slightly higher level in the lower abdomen gives sufficient exposure. In addition, the skin incision falls within the lines of Langer, so a good cosmetic result can be expected. When it is anticipated that a *midline incision* is indicated.

CA 125

The most extensively studied serum marker to distinguish benign from malignant pelvic masses is CA 125 It is most useful when nonmucinous epithelial cancers are present It is not of value in distinguishing other categories of ovarian malignancy The serum marker CA 125 level is elevated in 80% of patients with epithelial ovarian cancer Only in 50% of patients with stage I disease at the time of diagnosis, hence its lack of utility as a screening test

Ovarian Cycle: Ovulation

The number of oocytes is maximal in the fetus at 6 to 7 million at 20 weeks' gestation. Significant atresia (physiologic loss) of oogonia occurs so that at birth, only 1 to 2 million remain in both ovaries. At puberty (with ongoing atresia) between 300,000 and 400,000 oocytes are available for ovulation with only 400 to 500 actually ovulating. During each cycle, a cohort of follicles is recruited for development. Among the many developing follicles, only one (the dominant follicle) usually continues differentiation and maturation into a follicle that ovulates. Follicular maturation is dependent on the local development of receptors for FSH and LH. The preovulatory LH surge initiates a sequence of structural and biochemical changes that culminate in ovulation. A few hours preceding ovulation, the chromatin is resolved into distinct chromosomes, and meiotic division takes place with unequal distribution of the cytoplasm to form a secondary oocyte and the first polar body. Each element contains 23 chromosomes, each in the form of two monads. No further development takes place until after ovulation and fertilization have occurred. At that time, and before the union of the male and female pronuclei, another division occurs to reduce the chromosomal component of the egg pronucleus to 23 single chromosomes (22 plus X or Y), each composed of the one monad.

Pelvic Examination

The pelvic examination must be conducted systematically and with careful sensitivity. The procedure should be performed with smooth and gentle movements and accompanied by reasonable explanations. *Vulva* The character and distribution of hair The degree of development or atrophy of the labia The character of the hymen (imperforate or cribriform) and introitus (virginal, nulliparous, or multiparous) should be noted.

Normal Pelvic Anatomy and Supports

The pelvic organs, including the vagina, uterus, bladder, urethra, and rectum, are supported within the pelvis by the bilaterally paired and posteriorly fused levator ani muscles. The anterior separation between the levator ani is called the levator hiatus. The urethra, vagina, and rectum pass through the levator hiatus and urogenital diaphragm as they exit the pelvis. The endopelvic fascia is a visceral pelvic fascia that invests the pelvic organs and forms bilateral condensations referred to as ligaments (i.e., pubourethral, cardinal, and uterosacral ligaments). These ligaments attach the organs to the fascia of the pelvic side walls and bony pelvis. Damage to the vagina and its support system allows the urethra, bladder, rectum, and small bowel to herniate and protrude into the vaginal canal.

Placental Transport

The placenta has a very large surface area, which facilitates the transport of substances in both directions. The surface area at 28 weeks is 5 square meters, and at term it is almost 11 square meters About 5 to 10% of this surface area is extremely thin, measuring only a few microns. The bulk of the substances transferred from mother to fetus consists of oxygen, glucose, amino acids, and ketone bodies. The fetus eliminates carbon dioxide and waste materials (eg., urea and bilirubin) into the maternal circulation. The exchange of gases occurs via diffusion

Placenta Previa Four degrees?

The placenta is located over or very near the cervical os. Four degrees of this abnormality have been recognized: Complete-completely covers the internal os Partial-covers the internal os Marginal-reaches the internal os but never covers it Low-lying-extends into lower uterine segment but does not cover internal os Ultrasound , gentle vag speculum but not manual pelvic!! Like a pen dot on a balloon, the dot migrates away from the opening so a previa placenta may not be later on in the pregnancy.

The platypelloid pelvis

The platypelloid pelvis is best described as being a flattened gynecoid pelvis. It is found in only 3% of women, and it has the following characteristics: A short anteroposterior and wide transverse diameter, creating an oval-shaped inlet Straight or divergent sidewalls Posterior inclination of a flat sacrum A wide bispinous diameter Long but small sacrospinous notch A wide subpubic arch The overall shape is that of a gentle curve throughout. The fetal head has to engage in the transverse diameter.

Appendiceal Torsion: Dx

The presence of a nodule at the superior aspect of the testicle, with its characteristic blue-dot appearance, is pathognomonic.* Color Doppler sonography is the imaging modality of choice for evaluation of the acute scrotum.* If the diagnosis is unclear after the physical examination, a testicular ultrasound can be performed that will show the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area. Color Doppler reveals normal blood flow to the testis with an occasional increase on the affected side, possibly due to inflammation

Amenorrhea or Oligomenorrhea with Hyperprolactinemia and/or Galactorrhea

The principal action of prolactin is to stimulate lactation. Hypersecretion of prolactin leads to gonadal dysfunction by interrupting the secretion of GnRH, which inhibits the release of LH and FSH and thereby impairs gonadal steroidogenesis. The consequences of hyperprolactinemia that are clinically significant include menstrual disturbances and/or galactorrhea Normal serum prolactin levels are under 20 ng/dL, depending on the laboratory used. In patients with prolactin-secreting tumors, levels are usually above 100 ng/dL If clinically significant hyperprolactinemia is not explained by primary hypothyroidism or drug use, CT or MRI of the sella turcica should be performed. Besides galactorrhea, hyperprolactinemia frequently causes oligomenorrhea or amenorrhea.

Proliferative Phase

The proliferative phase is characterized by endometrial proliferation or growth secondary to estrogenic stimulation. Because the bases of the endometrial glands lie deep within the basalis, these epithelial cells are not destroyed during menstruation. During this phase of the cycle, the large increase in estrogen secretion causes marked cellular proliferation of the epithelial lining, the endometrial glands, and the connective tissue of the stroma. By the end of the proliferative phase, cellular proliferation and endometrial growth have reached a maximum, the spiral arteries are elongated and convoluted, and the endometrial glands are straight, with narrow lumens containing some glycogen.

Anesthesia for Cesarean Delivery Contraindications

The type of anesthesia selected for cesarean delivery is determined by the urgency of the surgery, the presence or absence of a preexisting epidural catheter for labor, the patient's medical condition, pregnancy-related complications, and the presence of any contraindications to regional anesthesia. *Absolute contraindications to Regional Anesthesia* Patient refusal coagulopathy Infection at needle insertion site Severe hypoveolemia with ongoing blood loss *Relative Contraindications* Prior back surgery Certain cardiac lesions—aortic stenosis Increased intracranial pressure

Anatomy of Ureters in a female

The ureters extend 25 to 30 cm from the renal pelves to their insertion into the bladder at the trigone. Each descends immediately under the peritoneum Crossing the pelvic brim beneath the ovarian vessels just anterior to the bifurcation of the common iliac artery In the true pelvis, the ureter initially courses inferiorly, just anterior to the hypogastric vessels It then passes forward along the side of the cervix and *beneath the uterine artery* toward the trigone of the bladder.

Uterus

The uterus consists of the cervix and the uterine corpus, which are joined by the isthmus. The cervix is generally 2 to 3 cm in length. At about the external cervical os, the squamous epithelium covering the ectocervix changes to simple columnar epithelium, the site of transition being referred to as the *squamocolumnar junction*. The uterine corpus is a thick, pear-shaped organ, somewhat flattened anteroposteriorly, that consists of largely interlacing *smooth muscle fibers*.

The anatomic position of the uterus may vary within the pelvic cavity

The uterus may tilt in a forward position— *anteverted* It may be only lightly forward—*mid position* It may tilt in a backward direction— *retroverted*

Vacuum Extraction

The vacuum extractor (VE) is an instrument that uses a suction cup that is applied to the fetal head. Flexion of the fetal head must be maintained to provide the smallest diameter to the maternal pelvis by placing the posterior edge of the suction cup 3 cm from the anterior fontanel squarely over the sagittal suture. Image of vacuum and application With the aid of maternal pushing efforts, traction is applied parallel to the axis of the birth canal. Detachment of the suction cup from the fetal head during traction is termed a "pop-off." The VE is contraindicated in preterm delivery because the preterm fetal head and scalp are more prone to injury from the suction cup. The VE is suitable for all vertex presentations, but unlike forceps, it must never be used for delivery of fetuses presenting by the face or breech. Forceps have a higher overall success rate for vaginal delivery. The failure rate for forceps is 7%, whereas the failure rate for vacuum extraction is 12%. In general, forceps deliveries cause higher rates of maternal injury, and vacuum extraction causes higher rates of fetal morbidity. Sequential use of one instrument followed by the other has been associated with a disproportionately high fetal morbidity rate Long-term retrospective studies of adolescents who were delivered by normal vaginal delivery, forceps, vacuum extractions, and cesarean delivery have shown little difference in physical or cognitive outcomes.

Vagina

The vagina is a flattened tube extending posterosuperiorly from the hymenal ring at the introitus up to the fornices that surround the cervix. Its epithelium, which is *stratified squamous* in type. The adult vagina averages about 8 cm in length, although its size varies considerably with age, parity, and the status of ovarian function. An important anatomic feature is the immediate proximity of the posterior fornix of the vagina to the pouch of Douglas, which allows easy access to the peritoneal cavity from the vagina, by either culdocentesis or colpotomy.

Vasa Previa

The velamentous insertion of fetal vessels over the cervical os - The fetal vessels lack protection from Wharton's jelly and are prone to rupture -The overall perinatal mortality for vasa previa is between 58 and 73 percent -The incidence of vasa previa has been reported as 1/2,000 to 5,000 deliveries Vasa previa usually presents after rupture of membranes with the acute onset of vaginal bleeding from a lacerated fetal vessel. If immediate intervention is not provided, fetal bradycardia and subsequent death occur STAT C section! If bleeding with rupture of membranes. Not Apt to have time to do APT test.

Breastfeeding

There are many advantages to breastfeeding. First, breast milk is the ideal food for the newborn, is inexpensive, and is usually in good supply. Second, nursing accelerates the involution of the uterus because suckling stimulates the release of oxytocin, thereby causing increased uterine contractions. Third, and probably most important, there are immunologic advantages for the baby from breastfeeding. Breastfeeding thereby provides the newborn with passive immunity

RH factor inheritance

There is a one from the mother and one from the father. There is dominant and resessive gene

Emergency Contraception

There is one main FDA-approved hormonal method used for use following coitus. The method is a series of products with high doses of the progestin levonorgestrel. Levonorgestrel suppresses ovulation up to the beginning of the luteinizing hormone (LH) surge. The efficacy of these products is inversely related to the time since exposure (4% failure rate at 72 hours) The most effective method of postcoital pregnancy prevention (with a failure rate of 1 in 1000) is the placement of a copper IUD within 5 days of coitus.

Uterine cycle:implantation window

There is only a brief time period of endometrial receptivity for implantation. As early as day 16 and as late as day 19. this is around the early to mid secretory phase of the uterine cycle. Fertilization normally occurs within one day of ovulation sot he effective window is less than 4 days.

Hot Flushes and Vasomotor Instability

This is usually the first and most common physical manifestation of decreasing ovarian function Recurrent and transient Sensation of warmth to intense heat of upper body and face During sleep associated with perspiration, night sweats. Night sweats can disturb sleep, causing sleep deprivation and can ultimately effect job productivity. Sleep Disturbances Declining E2 induce a changes in sleep cycle—decreasing ability to achieve restful sleep. The latent phase of sleep (time required to fall asleep) is lengthened. Secondary symptoms of irritability and difficulty with concentration can occur.

Corpus Luteum Cyst

This occurs after an egg has been released from a follicle The follicle becomes a corpus luteum. If a pregnancy doesn't occur, the corpus luteum usually breaks down and disappears It may, however, fill with fluid or blood and persist on the ovary. Usually, this cyst is found on only one side and produces no symptoms May rupture spontaneously Profuse bleeding common Surgical removal if Large hemorrhagic cyst Extensive peritoneal bleeding

Variable FHR Deceleration (Cord Compression)

This pattern has a variable time of onset and a variable form and may be nonrepetitive. Variable decelerations are caused by umbilical cord compression. Note that the decelerations have a more rapid drop and more rapid return to normal. The severity of variable decelerations is graded by their duration

Early FHR Deceleration (Head Compression)

This pattern usually has an onset, maximum fall, and recovery that is coincident with the onset, peak, and end of the uterine contraction. The nadir (middle) of the FHR coincides with the peak of the contraction. This pattern is seen when engagement of the fetal head has occurred. Early decelerations are not thought to be associated with fetal distress. The pressure on the fetal head leads to increased intracranial pressure that elicits a vagal response similar to the Valsalva maneuver in the adult.

General Physical Examination of a Pregnant individual

This procedure must be systematic and thorough and performed as early as possible in the prenatal period *Pelvic Examination*: The initial pelvic examination should be done early in the prenatal period and should include the following: inspection of the external genitalia, vagina, and cervix Pap smear Palpation of the cervix, uterus, and adnexa. The initial estimate of gestational age by uterine size *Clinical Pelvimetry*: helpful for predicting potential problems during labor Urine/blood Ultrasound

Fetal Short-term or beat-to-beat variability

This reflects the interval between either successive fetal electrocardiographic signals or mechanical events of the cardiac cycle. Normal short-term variability fluctuates between 6 and 25 beats/min. Variability below 5 beats/min is considered to be potentially abnormal. When associated with decelerations, a variability of less than 5 beats/min usually indicates severe fetal distress. A prolonged flat baseline is the result of fetal acidosis

Sertoli-Leydig Tumor

This tumor produces both Sertoli and Leydig cells Sertoli-Leydig cell tumor is a rare cancer < 0.5% cancer cells produce and release a male sex hormone cause virulization symptoms Low grade malignancy Affects young women less than age 30

Follicular Cysts:

This type of simple cyst can form when ovulation does not occur or when a mature follicle involutes (collapses on itself). It usually forms at the time of ovulation and can grow to about 2.3 inches in diameter. The rupture of this type of cyst can create sharp severe pain Usually spontaneously reabsorbed Can employ a "wait and see strategy for 8-10 weeks Mass must be evaluated (laparoscopy) if still present

Evaluation of infertility

Thorough medical history and evaluation to include Medical disorders Medications Prior surgeries Pelvic infections, pelvic pain Sexual dysfunction Environmental and lifestyle factors (diet, exercise, tobacco use, drug use)

Recurrent Abortion

Three successive spontaneous abortions usually occur before a patient is considered to be a recurrent aborter.

Involution of the Uterus

Through a process of tissue catabolism, the uterus rapidly decreases in weight from about 1000 g at delivery to 100 to 200 g approximately 3 weeks postpartum. For the first few days after delivery, the uterine discharge (lochia) appears red (lochia rubra), because of the presence of erythrocytes. After 3 to 4 days, the lochia becomes paler (lochia serosa), and by the tenth day, it assumes a white or yellow-white color (lochia alba). Foul-smelling lochia suggests endometritis. *Return of Menstruation and Ovulation* In women who do not nurse, menstrual flow usually returns by 6 to 8 weeks, although this is highly variable.

Genital Herpes Simplex - Clinical Manifestations

Transmission through direct contact *usually during asymptomatic shedding Primary infection commonly asymptomatic symptomatic cases severe, prolonged, systemic manifestations Vesicles result in painful ulcerations leading to crusting Recurrence a potential

HPV

Transmission: skin-to-skin contact *High-risk (16, 18 etc) vs low-risk (6, 11 etc) types Low-risk types: genital warts High-risk HPV infection is causally associated with cervical cancer and other anogenital squamous cell cancers (e.g. anal, penile, vulvar, vaginal) Diagnosis: Clinical exam, cytology, nucleic acid amplification methods (in conjunction with cytology for high-risk HPV types) *Treatment: Topical and destructive modalities

Treatment of Cyclic breast pain

Treat if adversely effecting lifestyle Evening Primrose NSAIDs or acetaminophen Both cyclic and non-cyclic pain Abstain from caffeine Diet- low fat and high in complex carbs Supportive bra with proper fit Danazol (Anti-Androgen) Lowering estrogen dose in HRT Vitamin E supplementation

Prostate Cancer Treatment

Treatment depends on age & life expectancy of pt. -Surgery w/ midline incision. Works well to eradicate CA in early stages. But may leave pt. w/ incontinence. Interstitial Brachytherapy* - small needles placed into the prostate & small radiation seeds are placed to radiate it from the inside out Cryoablation* - needles are placed into the prostate - freezing of the prostate (not well accepted) Hormone Removal - Remove testes, drugs that stop hormone production* External beam radiation w/ gamma radiation. Once CA metastasizes to bone, it's incurable.

Appendiceal Torsion: Rx

Treatment: Necrotic tissue of the testicular appendices causes no damage other than damage to itself. Most cases, therefore, are treated conservatively. Pain usually resolves over a week. NSAIDS* Ice Recovery is generally slow with this approach, and pain may last for several weeks to months. Surgical excision of the appendix testis is reserved for patients who have persistent pain.

Epididymitis: Rx

Treatment: Bed rest with scrotal elevation -Treat the most likely pathogen. -If under 40 treat for STD's. Sexual partner should also be treated.* -If over 40, assume not STD and treat for UTI's.* Acute epididymitis most likely caused by sexually transmitted chlamydia and gonorrhea should be treated with ceftriaxone (250 mg intramuscular injection in one dose) plus doxycycline (100 mg by mouth twice a day for 10 days). Azithromycin may be an alternative option in patients who are unable to tolerate doxycycline. Acute epididymitis most likely caused by sexually-transmitted chlamydia and gonorrhea and enteric organisms (men who practiced insertive anal sex) should be treated with ceftriaxone along with a fluoroquinolone that covers enteric organism. Acute epididymitis most likely caused by enteric organisms (eg, men with a negative gram stain or nucleic acid amplification test for N. gonorrhoeae or men with epididymitis after urinary-tract instrumentation procedures) may be treated with fluoroquinolones alone (ofloxacin 300 mg by mouth twice a day for 10 days or levofloxacin500 mg by mouth once daily for 10 days).

True Knot & False Knot of the umbilical cord

True knots and false knots form in the umbilical cord True knots occur in approximately 1% of pregnancies- highest rate occurring in monoamnionic twins False knots (kinks in the umbilical cord vessels)- more common True knots arise from fetal movements- more likely to develop during early pregnancy, when relatively more amniotic fluid is present and greater fetal movement occurs. True knots associated with: advanced maternal age multiparity long umbilical cords. True knots reported to lead to a 4-fold increase in fetal loss, presumably because of compression of the cord vessels when the knot tightens. False knots have no known clinical significance

Diagnosis & Management Uterine Rupture

Typically, rupture is characterized by the sudden onset of intense abdominal pain. The presenting part may be found to have retracted on pelvic examination Fetal death or long-term neurologic sequelae may occur in 10% of cases. In most cases, total abdominal hysterectomy is the treatment of choice, although debridement of the rupture site and primary closure may be considered in women of low parity who desire more children. Maternal-fetal Risk Although the associated maternal mortality rate is now less than 1% The associated fetal mortality rate is still about 30%.

Amenorrhea or Oligomenorrhea with Breast Development and Normal Müllerian Structures

Typically, women with oligomenorrhea have fewer than nine menstrual cycles per year. All patients with menstrual bleeding disorders should be tested for pregnancy History-taking should include questions about the timing of thelarche, pubarche, and menarche In addition to a pregnancy test, the initial investigation of the amenorrheic patient should include: serum FSH level progestin challenge test

Gyn Imaging Studies

Ultrasonography Diagnositic Indications: evalution of pelvic organs, cysts and tumors Sonohysterography Diagnositic Indications: evaluation of uterine cavity for polyps or tumors Hysterosalpingography` Diagnositic Indications: evalution of uterine cavity and fallopian tube for patency

Vulvar & vaginal Cancer

Uncommon 2.5/100,000 Post menopausal (65) 60% related to HPV (16 & 33) Chronic Inflammation or Autoimmune Process Vulvar plaque, ulcer or mass (can also involve perianal and cervix) Pruritus Bleeding, dysuria and enlarged lymph nodes are signs of advanced disease *Diagnosis*: Based on Biopsy 5% acetic acid and colposcopy exam and biopsy

Contraindications to HRT

Undiagnosed abnormal genital bleeding Known or suspected estrogen-dependent neoplasia Active DVT, PE or history of these conditions Active or recent arterial thromboembolic disease (stroke, MI) Liver dysfunction or liver disease Known or suspected pregnancy Hypersensitivity to HRT preparations

Breast Pain - Non cyclic

Unrelated to menstrual cycle Unilateral pain (often focal) *Local* Cyst Rupture of ectatic duct Mastitis Fibroadenoma *General* Stretching cooper's ligaments Pressure from bra Fat necrosis following trauma Hidradenitits suppurativa Mondor's disease

Diagnostic Cone Biopsy

Unsatisfactory colposcopy Endocervical curetting show a high grade lesion Pap smear shows high grade lesion not confirmed by biopsy Pap smear indicate adenocarcinoma in situ Microinvasion is present on biopsy

Lower Urinary Tract Symptoms (LUTS)

Urinary incontinence is a lower urinary tract symptom Classification of LUTS: Filling symptoms: urinary frequency, urgency, dysuria, nocturia Voiding symptoms: poor stream, hesitancy, terminal dribbling, incomplete voiding Others: incontinence, pelvic pain Urinary incontinence definition: Involuntary leakage of any amount of urine sufficient to be a health and/or social problem

Urinary Incontinence female

Urinary incontinence is defined as the involuntary loss of urine that is a social or hygienic problem Urinary incontinence has been reported to affect 15-50% of women. Anatomy and Physiology of the Lower Urinary Tract The striated muscular urethral sphincter, which surrounds the distal two-thirds of the urethra, contributes about 50% of the total urethral resistance and serves as a secondary defense against incontinence.

Maternal complications

Urinary tract infections Vaginal bleeding Hypertension Postpartum complications Issues may be repetitive; such knowledge is helpful in anticipating and preventing problems with the present pregnancy.

Normal Micturition and the autonomic nervous system

Urine storage is under sympathetic control Inhibits detrusor contraction Increases sphincter contraction Voiding is under parasympathetic control Induces detrusor contraction Induces sphincter relaxation

AIDS Dementia Complex

Usually in advanced disease. Insidious onset progressing over months-years. Poor concentration Decreased memory Motor dysfunction Progressive ataxia and spasticity Incontinence Behavioral changes Social withdrawal and apathy Need to rule out depression especially with psychomotor retardation CT/MRI with cerebral atrophy and enlarged sulci with normal CSF examination

Usual Ductal Hyperplasia of the breast

Usually incidental finding on Biopsy secondary to abnormal mammogram findings or palpable mass Increased cells in ductal space No additional treatment required

Uterine Rupture

Uterine rupture implies complete separation of the uterine musculature through all of its layers, ultimately with all or a part of the fetus being extruded from the uterine cavity. The overall incidence is 0.5% A prior uterine scar is associated with 40% of cases. With a prior lower-segment transverse incision, the risk for rupture is less than 1%, whereas the risk with a high vertical (classical) scar is 4-7%. Sixty percent of uterine ruptures occur in previously unscarred uteri.

Acute bacterial epididymitis

can cause serious illness in rare cases. This is characterized by severe swelling and exquisite pain of surrounding structures, often accompanied by high fever, rigors, and irritative voiding symptoms (frequency, urgency, dysuria) secondary to an associated urinary tract infection Urinary symptoms are also commonly seen in conjunction with acute prostatitis (epididymo-prostatitis), particularly in older men who may have underlying prostatic obstruction or have undergone recent urologic instrumentation. Men who engage in anal insertive intercourse are also at increased risk for epididymitis due to exposure to coliform bacteria in the rectum